Implementation
Naloxone kits were assembled in preparation for program implementation. Each kit contained 2 vials of naloxone (each vial contains 1 dose), 2 needleless luer-lock syringes, and 1 atomizer with visual instructions for product assembly. Next, a template was created for entry into the veteran’s electronic health record (EHR) each time a naloxone kit was dispensed. The template tracked diagnosis, history of naloxone kit use, and aspects of the OEND program that were discussed with the veteran. Embedded within the template is a hyperlink to the Substance Abuse and Mental Health Services Administration Opioid Overdose Prevention Toolkit booklet, which serves as an education guide and take-home material for the veteran.
Once the naloxone kits were assembled and the template created, SA providers were able to engage in OEND program training. Training required providers to attend a 60-minute, 75-slide PowerPoint seminar, highlighting risk factors and prevention strategies for opioid overdose, proper identification and management of an opioid overdose, appropriate administration of naloxone, and monitoring parameters after administration. Providers were not screened for baseline knowledge, nor was a posttraining proficiency evaluation performed. However, providers were allowed to ask questions and request further clarification about any unclear aspects of training.
Each month, data were collected on the number of providers trained and naloxone kits dispensed. Implementation began in January 2015, and veterans were either educated during individual or group sessions led by a trained OEND provider. An institutional review board-approved quality improvement (QI) process ran concurrently that sought to improve the OEND program. Phase 1 of this QI project anonymously surveyed OEND providers to evaluate knowledge, comfort, attitude, and fear of consequences regarding naloxone distribution in an attempt to understand barriers to program implementation or success.7 In phase 2, veterans who received a naloxone kit will be interviewed regarding knowledge retention of OEND program education and subsequent opioid abuse and naloxone use after receiving a naloxone kit.
Results
From January 2015 through preliminary data analysis in April 2015, the facility trained 19 providers and dispensed naloxone kits to 49 veterans. In the first 4 months of program implementation, there were no reports of attempted opioid overdose reversals with naloxone in the 49 veterans who had received a naloxone kit. Of note, past studies have demonstrated that 1 death is prevented for every 227 naloxone kits distributed.8 Therefore, it is possible that the analysis was too early to detect an impact.
As of October 2016, VACT has dispensed 538 naloxone kits to 441 veterans, as some patients have received naloxone kit refills for various reasons (ie, lost, used, confiscated, stolen, etc). The OEND program implementation team has been made aware that at least 5 of the 441 veterans have used naloxone kits, though it is unclear whether naloxone kits were used on the veteran themselves or someone else. This is likely an underestimate of naloxone kit use, as veterans could be sent to alternative hospitals in the event of an opioid overdose, or veterans may not disclose actual use of naloxone kit to VACT providers. Phase 2 of the QI project is designed to extract an estimation of actual naloxone kit use in the VACT veteran population.
Discussion
Naloxone, a pure opioid antagonist, is readily available in many communities. In order to extend the same continuity of care to veterans, VACT implemented the OEND program to increase access to naloxone kits. This program serves as an opportunity to educate veterans regarding safe practices with opioids and provides a life-saving measure in the event of an overdose.
The 4-step approach to implementation was a feasible method of quickly implementing an OEND program. Despite ongoing prescriber interest in participating in the OEND program, barriers to implementation were encountered. The largest barrier was provider concerns related to an increase in opioid use given the availability of a reversal agent. However, the medical literature suggests that opioid use tends to decrease when naloxone programs are implemented. Additionally, OEND implementation barriers were internally analyzed in an effort to foster a successful OEND program with continuous evaluation and improvement.7
Clark and colleagues examined 19 published studies regarding community-based naloxone programs in order to assess whether naloxone distribution reduced fatal and nonfatal overdose rates.9 Naloxone was used successfully across 1,949 patients, and 8 studies reported survival rates of 83% to 96% after naloxone, while 11 studies reported 100% survival rate. The authors of a study of the Chicago Recovery Alliance program found an overall decrease in heroin overdose, and the initial downward trend was seen during the year of naloxone implementation.9
In addition, the cost of program implementation was minimal at the local level. Given that implementation of OENDs is a national VA mandate, all naloxone kits are provided to individual VA facilities at no cost from the Consolidated Mail Outpatient Pharmacy, which is the only foreseeable tangible cost. Therefore, intangible costs may include time spent implementing the OEND program, time spent maintaining naloxone inventory, time spent discussing and educating patients on naloxone, and time spent dispensing naloxone kits to patients. However, the intangible costs of the program are predicted to be reduced or offset by the cost-savings measure of reduced emergency department visits and hospitalizations for opioid overdose.
By implementing the OEND program at VACT, veterans are able to engage in primary prophylaxis via education regarding safe practices of opioids. These veterans are also able to obtain tertiary prophylaxis by receiving a naloxone kit and associated training. It is predicted that deaths due to opioid overdose will decrease in this veteran population with the expansion of the OEND program.
Scientific Significance
The OEND programs increase naloxone access and can potentially decrease the incidence of opioid misuse and fatal opioid overdose.
Conclusion
An OEND program can be easily implemented to dispense naloxone kits and deliver education regarding safe opioid use.
