TY - JOUR AU - Zhang, Maria AB - North America continues to experience significant rates of opioid-related sequelae, including overdose deaths. This has been one of the most devastating public health issues in recent history as opioid-related deaths continue to occur despite the existence of an antidote and an overwhelming majority of those deaths being unintentional.1 In fact, recent trends of life expectancy declines or stagnation in the United States and Canada have been attributed to drug overdose deaths.2,3 In the United States, the age-adjusted rate of drug overdose deaths increased from 6.1 per 100,000 standard population in 1999 to 21.7 per 100,000 in 2017.4 In Canada, the rate ranged from 8.4 per 100,000 population in 2016 to 11.9 per 100,000 in 2018.1 The etiology of the current opioid crisis is multifactorial; it involves a combination of opioid overprescribing, misleading marketing strategies of pharmaceutical companies, lack of objective education on pain and addiction treatment for healthcare professionals, shifts in drug availability and preference over time, the advent of high-potency fentanyl analogues, and persistent stigma at every level against people who use drugs.5 As such, the solution to the opioid crisis must be multifaceted. Federal governments across North America have put forth strategic action plans to address the crisis. For example, the Canadian government committed to increased reporting and data collection, awareness and prevention efforts, and access to treatment and harm reduction programs.6 One tangible result of this pledge to improve access to treatment and reduce harm was making naloxone available to individuals without a prescription across Canada.7 Nationally, all provinces and territories maintain publicly funded take-home naloxone programs, with varying access points. Depending on the jurisdiction, free injectable and/or intranasal (IN) take-home naloxone kits may be available through public health agencies, emergency departments, and/or community pharmacies.8 In Ontario, Canada’s most populous province, with the third-highest rate of opioid-related mortality nationally, pharmacies receive remuneration for the training and dispensing of injectable and IN take-home naloxone kits.1,9 These national and provincial changes increased availability of naloxone while simultaneously supporting pharmacists’ existing interest in improving access to harm reduction strategies.10-12 Health system overview As one of the leading mental health teaching hospitals in Canada, the Centre for Addiction and Mental Health (CAMH) has long been involved in research, education, and direct patient care efforts to prevent and manage opioid-related sequelae, including opioid overdoses and opioid use disorder. Even with these coordinated, multipronged efforts, the local impact of the opioid crisis continued to grow, as demonstrated by the number of emergency department visits, hospitalizations, and deaths.13 As a result, the executive leadership of the organization committed human and financial resources to launch a formal Opioid Overdose Prevention Initiative. An interprofessional team with addiction and change management expertise was assembled to brainstorm major deliverables for the initiative and to facilitate its successful implementation. Key goals included improved screening and documentation of opioid overdose risk assessments within the electronic health record, provision of education to patients and their loved ones around overdose prevention and management, and timely access to free take-home naloxone kits. The role of “opioid overdose prevention pharmacist” was the only de novo role that received organizational funding as part of the initiative; in part, this arrangement capitalized on federal and provincial changes whereby take-home naloxone kit education and distribution was a billable service for outpatient pharmacists affiliated with a community pharmacy, such as the one on-site within our institution. Program description CAMH is Canada’s largest mental health and addictions institution, focusing on direct patient care, research, education, and policy. In 2018, 37,065 unique patients obtained inpatient and/or outpatient care at CAMH. Most frequently, patients presented with schizophrenia or related disorders along with psychosis (31.6%) or substance use disorders (31.5%).14 Concurrent disorders were prevalent, with 50% of inpatients having more than 1 diagnosis in the 2018-2019 period.14 Care is provided by over 3,000 staff and 400 physicians across 2 sites in downtown Toronto, Ontario. Given the high prevalence of substance use and related disorders amongst patients presenting to CAMH, clinicians practice within a recovery-based model incorporating harm reduction whenever possible. However, prior to 2017 provision of harm reduction supplies, such as clean needles and syringes and related comprehensive education, was frequently limited to one ambulatory addictions service. Simultaneously, from July 2017 through June 2018, Ontario experienced a record-high number of opioid-related deaths, with the greatest number occurring in Toronto.15 Across the province, the health histories of individuals whose deaths were unintentional and resulted from opioid use (n = 1,209), were frequently significant for opioid use disorder (62.6%), another substance use disorder (43.6%), alcohol use disorder (27.0%), depression (23.7%), and/or pain (18.9%). Simultaneously, the crisis was also quickly evolving; among the accidental opioid-related deaths, fentanyl and fentanyl analogues directly contributed to 71.2% of the deaths, and nonopioid substances that most often contributed to death included stimulants such as cocaine (in 33.9% of cases) and methamphetamine (14.6%).15 Recognizing that clients across the CAMH system had been or were going to be affected by the opioid crisis at a growing rate, the organization invested significant resources to develop a formal Opioid Overdose Prevention Initiative. Training process The organization’s senior leadership originally approached the pharmacy department with an interest in acquiring naloxone kits for distribution as part of the organization’s response to the local opioid crisis. Through further conversation, the money allocated for naloxone kit acquisition was redirected to the creation of a time-limited clinical pharmacist position focused on educating patients, family members, CAMH staff, and physicians. The opioid overdose prevention pharmacist worked with an interdisciplinary team to bring awareness to the escalating and evolving opioid overdose crisis and to provide staff and clients with tangible knowledge and skills in prevention, identification, and management of opioid overdose. Organization-wide naloxone training The pharmacist led one-on-one and group training sessions for patients, their loved ones, members of the public, staff, and physicians. Engaging patients and their loved ones in frank and respectful conversations about minimizing overdose risk, with a focus on harm reduction, was foundational to the pharmacist’s training sessions. This training included guidance on recognizing signs and symptoms of opioid poisoning and the importance of contacting emergency first responders given naloxone’s short half-life. For staff, training involved education on appropriate harm reduction interventions through use of standardized tools as well as the promotion of resources for patients detailing where to access naloxone kits. All sessions carried out by the pharmacist included a hands-on demonstration of how to use both intramuscular (IM) and IN naloxone according to a protocol developed by the local public health unit. Those who attended the session were able to choose which free naloxone kit(s) they wanted to receive (IM, IN, or both). The kit contents included 2 doses of naloxone (2 commercially available naloxone nasal sprays [4 mg/0.1 mL] or 2 ampules or vials of naloxone 0.4 mg/mL), a printed handout with instructions for use, a facemask for cardiopulmonary resuscitation, gloves, and a card indicating that the individual had received proper training on how to use the kit. Specific to the IM naloxone kit, 2 needles with syringes along with 2 alcohol swabs were also included. From August 2017 through January 2020, the pharmacist dispensed over 1,563 kits and provided training to eligible individuals as part of the publicly funded take-home naloxone kit program for pharmacies. Online module The “Opioid Overdose Prevention and Management” training program for staff began as an in-person, 45-minute group training session led by the pharmacist and a nurse. This presentation focused on a broad overview of the national, provincial, and local opioid crises, information regarding the benefits of and caveats to naloxone use, and the roles and responsibilities of staff if they encounter an opioid overdose on- or off-site (for example, during a home visit). In order to disseminate this information to staff hospital-wide, an interactive online module was developed using the authoring application Articulate (Articulate Global, Inc., New York, NY). The e-training is organized into 3 modules, with questions incorporated throughout to test knowledge acquisition. The first module focuses on the current landscape of the opioid crisis, the link between substance use and other psychiatric disorders, and risk factors for opioid overdose. The second module focuses on naloxone, including how it works to address an opioid overdose and how to correctly identify and respond to an opioid overdose and administer naloxone. Lastly, the third module highlights the role of CAMH staff in relation to the opioid crisis by outlining key organizational policies, demonstrations of how to use assessment and documentation tools within the electronic health record, and ways to engage clients in discussions about opioid overdose prevention. To assess the impact of both the in-person training sessions and the online e-module for staff, nonmandatory, delinked pre- and post-training surveys were used. Survey results from over 430 staff members indicated that the training significantly increased staff willingness to engage clients in conversations about harm reduction, recommend naloxone kits, and assess risk of overdose. There were no significant differences in response by training delivery method (in person vs online). Most recently, this module has been incorporated as a mandatory component of code blue training for all clinicians, demonstrating its utility across the organization. Standardized assessment and documentation A standardized documentation tool was developed to guide clinicians’ assessments and interventions to reduce clients’ overdose risk. This documentation form follows an “ask, advise, assist” approach (appendix). Specifically, clinicians first assess a client’s risk of opioid overdose by ascertaining key information (eg, Does the individual use prescription opioids, “street opioids,” other street substances, and/or other central nervous depressants such as alcohol or benzodiazepines? Does the client use substances alone?). Subsequently, the clinician advises on safer use via individualized harm reduction principles (eg, use with a friend or in an area where the user can be found quickly). Lastly, clinicians assist clients by recommending specific interventions (eg, referral for harm reduction supplies and/or naloxone, written educational material). From August 2017 through January 2020, 7,997 standardized assessments were documented in the electronic health record. Anecdotally, clinicians have found this form to be easy to use, streamlined, and relevant to their practice. Educational materials for internal and external stakeholders To expand access to take-home naloxone kits, a “Checklist for Naloxone Training” was developed by the pharmacist to guide clinicians within and external to the organization through the key steps involved in training an individual on naloxone administration and to serve as a documentation tool within outpatient pharmacies. The checklist is based on the steps set out by the local Toronto Public Health Unit and was developed by the pharmacist. The checklist begins with prompting questions designed to gather more information about the person receiving the training in order to provide more applicable and personal advice. It then highlights the signs of respiratory depression and the steps of responding to respiratory depression, including calling 911, administering naloxone followed by rescue breaths, assessing the need for a second dose, and what to expect after administering naloxone. The last section focuses on harm reduction tips to promote safe drug practices (eg, avoid mixing multiple sedating substances and/or medications). In addition, a training video was developed for CAMH staff to further facilitate education on opioid overdose response, including a visual demonstration of IN and injectable naloxone administration and harm reduction principles. Through use of these educational tools, naloxone training has been standardized across the organization. In line with CAMH’s mandate to inspire change “beyond its four walls,” the naloxone training checklist is also accessible to external stakeholders (eg, hospital staff, community pharmacies, public health units, safe injection sites) via the organization’s website. Full-time permanent pharmacist position In light of the pharmacist’s impact, including an increase in the number of naloxone kits distributed and improvements in staff confidence and willingness to participate in harm reduction initiatives, the position was converted to a full-time permanent position. The pharmacist continues to be involved in opioid-related education across the organization and provides direct patient care within an “addictions ambulatory service.” Within this service, the pharmacist provides patients with naloxone kits and training and recommends changes for any modifiable risk factors for opioid overdose; this may include optimizing opioid agonist treatment or deprescribing sedating medications. Challenges The success of the initiative required increased awareness and publicity throughout the hospital. CAMH’s internal website was used as a platform to publish and disseminate information to promote the initiative and the role of pharmacists. In addition, posters advertising the initiative were displayed throughout hospital premises to create a safe space for clients and staff to talk about opioid overdose prevention. There were certain aspects of the initiative that did not fare as well as planned. For example, drop-in hours were established so that clients and staff could come to meet the pharmacist for naloxone training and dispensing. Despite ample awareness of this particular service, there was not enough uptake to justify its continuation. To address this issue, the pharmacist began participating in patient group meetings instead. There were also challenges associated with precepting students, as the schedule became quite unpredictable in terms of the number of training sessions planned, referrals for naloxone training, and/or medication reconciliation support. Instead of precepting one learner longitudinally, the pharmacist became involved in numerous teaching opportunities, including the facilitation of harm reduction debriefings with multiple pharmacy students completing their placement at CAMH and lecturing on opioid overdose recognition and management at University of Toronto’s Faculty of Pharmacy. Discussion The Opioid Overdose Prevention Initiative described here represents a unique and innovative strategy to address an urgent public health issue that continues to cause thousands of preventable deaths across North America. National and provincial changes aimed at improving access to harm reduction programs catalyzed the creation of the opioid overdose prevention pharmacist position at CAMH. The pharmacist acted as the central developer and coordinator of key deliverables, including an opioid overdose risk assessment tool, as well as providing much of the education and training across the organization. The initiative began with the pharmacist training clinicians within outpatient addictions services, as their clients were deemed to be at highest risk for opioid-related sequelae. Since then, training has been delivered via in-person sessions to inpatient units and other outpatient clinics. Furthermore, the interactive online module was developed and is now a mandatory component of code blue training for all clinicians in the organization. Interprofessional collaboration was a key facilitator, and buy-in from senior leadership was essential in allocating resources to fund the pharmacist position initially and on an ongoing basis. Frontline staff were eager to embrace the core components of the initiative and incorporate them into their everyday practice, thus contributing to the initiative’s overwhelming success. The benefits of this initiative have extended beyond CAMH, such that resources have been made available to other organizations and can be modified and adapted to suit their needs. The pharmacist continues to be available for consultation by other institutions for implementation advice and knowledge translation at a health-systems level. The pharmacist continuously revises and adapts resources to adapt to the fast-changing landscape of the opioid crisis and to ensure that the information remains in line with best practices. Training of staff will continue through the sustainable online e-module, with a goal of increasing awareness of opioid overdose prevention and addictions across the organization and beyond. Implementation of the initiative across a large Canadian mental health hospital was not without challenges and limitations. The program benefited from government and organizational support for pharmacists’ role in harm reduction. Unfortunately, this support may not be generalizable to all health systems due to wide-ranging laws and regulations and potential negative perceptions of harm reduction programs despite strong evidence for their benefits. Although this initiative involved both in-person training and use of an online e-module, some learners may have different learning styles (eg, active learning) that would have been better supported by alternative teaching methods. Additionally, the pre- and post-training surveys embedded in the training sessions were not mandatory and thus might not have captured data on all staff members who completed the training. Closing notes The Opioid Overdose Prevention Initiative demonstrated the role of pharmacists in harm reduction, especially naloxone provision and education. Organizational support and interprofessional collaboration, along with the federal and provincial governments’ support for pharmacists’ role in harm reduction and reimbursement for take-home naloxone kits and training, were key in creating and facilitating the success of the initiative. The Frontline Pharmacist column gives staff pharmacists an opportunity to share their experiences and pertinent lessons related to day-to-day practice. Topics include workplace innovations, cooperating with peers, communicating with other professionals, dealing with management, handling technical issues related to pharmacy practice, and supervising technicians. Readers are invited to submit manuscripts, ideas, and comments to AJHP, at ajhp@ashp.org. Disclosures: The authors have declared no potential conflicts of interest. This article is part of a special AJHP theme issue on substance use disorder. Contributions to this issue were coordinated by Nicole M. Acquisto, PharmD, FASHP, FCCP, BCCCP, and Zlatan Coralic, PharmD, BCPS References 1. Special Advisory Committee on the Epidemic of Opioid Overdoses, Public Health Agency of Canada . Opioid-related harms in Canada . https://health-infobase.canada.ca/substance-related-harms/opioids. Accessed July 24, 2020 . 2. Centers for Disease Control and Prevention . CDC in action: 2018 response to the opioid crisis . https://www.cdc.gov/opioids/pdf/Overdose-Snapshot-2018_Final_508.pdf. Published 2019 . Accessed July 24, 2020 . 3. Statistics Canada . Changes in life expectancy by selected causes of death, 2017 . https://www150.statcan.gc.ca/n1/daily-quotidien/190530/dq190530d-eng.htm. Published May 30, 2019 . Accessed July 24, 2020 . 4. Hedegaard H , Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2018 . National Center for Health Statistics, US Centers for Diseases Control and Prevention website. https://www.cdc.gov/nchs/products/index.htm. Published January 2020 . Accessed July 24, 2020 . 5. Buchman DZ , Orkin AM, Strike C, Upshur REG. Overdose education and naloxone distribution programmes and the ethics of task shifting . Public Health Ethics. 2018 ; 11 ( 2 ): 151 - 164 . Google Scholar Crossref Search ADS WorldCat 6. Johnson K , Jones C, Compton W, et al. Federal response to the opioid crisis . Curr HIV/AIDS Rep. 2018 ; 15 ( 4 ): 293 - 301 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Government of Canada . Notice: Prescription Drug List (PDL): naloxone . https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/prescription-drug-list/notice-naloxone.html. Published March 22, 2016 . Accessed July 24, 2020 . 8. Canadian Pharmacists Association . Publicly-funded take-home naloxone in pharmacies across Canada . https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Naloxone_Scan.pdf. Published 2019 . Accessed July 24, 2020 . 9. Ministry of Health and Long-term Care . Ontario Naloxone Pharmacy Program- The Ontario Drug Benefit (ODB) Program - Public Information - MOHLTC . 10. Watson T , Hughes C. Pharmacists and harm reduction: a review of current practices and attitudes . Can Pharm J (Ott). 2012 ; 145 ( 3 ): 124 - 127.e2 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Bagley SM , Peterson J, Cheng DM et al. Overdose education and naloxone rescue kits for family members of individuals who use opioids: characteristics, motivations, and naloxone use . Subst Abus. 2015 ; 36 ( 2 ): 149 - 154 . Google Scholar Crossref Search ADS PubMed WorldCat 12. McDonald R , Strang J. Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria . Addiction. 2016 ; 111 ( 7 ): 1177 - 1187 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Public Health Ontario . Interactive Opioid Tool: opioid-related morbidity and mortality in Ontario . https://www.publichealthontario.ca/en/data-and-analysis/substance-use/interactive-opioid-tool. Published 2020 . Accessed July 24, 2020 . 14. Centre for Addiction and Mental Health . Annual report 2018-2019 . https://www.camh.ca/en/driving-change/about-camh/performance-and-accountability/annual-report-and-financial-statements/annual-report-2018-2019. Accessed July 24, 2020 . 15. Ontario Agency for Health Protection and Promotion, Public Health Ontario . Opioid Mortality Surveillance Report: Analysis of Opioid-Related Deaths in Ontario July 2017-June 2018 . https://www.publichealthontario.ca/-/media/documents/O/2019/opioid-mortality-surveillance-report.pdf. Published 2019 . Access July 24, 2020 . Appendix—Checklist for opioid overdose prevention documentation 1. Ask about risk factors for opioid overdose (check all that apply): Uses opioids obtained from pharmacy Uses opioids obtained from unregulated sources (eg, heroin or street oxys) Uses other street drugs Uses benzodiazepines (eg, lorazepam) with opioids or street drugs Uses alcohol with opioids or street drugs Spends time with people at risk for opioid overdose (eg, who meet any of the criteria above) Other: 2. Advise on the strategies to reduce risk of overdose (check all that apply): Call 911: Canadian law protects you from possession charges when you report an overdose Carry a naloxone kit and make sure someone else is trained to help you use it Don’t use alone. Use somewhere you will be found quickly, in case you overdose Tolerance is quickly lost. If you have not used for a few days, use a very small test dose first Avoid mixing drugs (especially sedating drugs) Consider opioid maintenance treatment, like methadone, or buprenorphine (in Suboxone) Carry identification that you are on an opioid Tell your family and friends that you are on an opioid Learn CPR 3. Assist to access resources/overcome barriers: Motivational interviewing offered about specific strategies Client was referred to CAMH Outpatient Pharmacy or community pharmacy for initial naloxone kit or refill Give an opioid overdose wallet card Referred for harm reduction supplies Client was shown what a naloxone kit looks like Team Treatment Plan initiated/updated Provided client with Opioid Prevention written resource Comments: 4. Naloxone training: Naloxone kit and training was provided Name of pharmacist: __________ © American Society of Health-System Pharmacists 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) TI - The innovative role of an “opioid overdose prevention pharmacist” at a mental health teaching hospital JF - American Journal of Health-System Pharmacy DO - 10.1093/ajhp/zxaa407 DA - 2021-01-20 UR - https://www.deepdyve.com/lp/oxford-university-press/the-innovative-role-of-an-opioid-overdose-prevention-pharmacist-at-a-TephukFyYP SP - 292 EP - 296 VL - 78 IS - 4 DP - DeepDyve ER -