Naloxone Education, Training, Certification and Dispensing

Andrea Mathias MD MPH

Deputy Health Officer

Worcester County Health Department

National Opioid Death Rate Trend

Maryland Deaths-Selected Substances

Drug Use Among Teens

Available from: http://www.theantidrug.com/pdfs/prescription_report.pdf

High Risk for Opioid Death

Doctor Shoppers

PolyPharmacy

Low-income and living in rural areas.

Medicaid : 2X rate of Rx painkillers

6X the risk of Rx painkillers overdose.

People with mental illness, a history of substance abuse.

White, female (NEW)

**Youth : accidental combinations**

Naloxone Harm Reduction Program

1. GOAL: (Like Epi-Pens): place rescue dose in

proximity to opioid user- as bridge to EMS (Caregiver, family , layperson=First responder)

2. As of 2010, there were 48 known programs in the United States , 188 community-based sites in 15 states and Washington, DC

3. Since 2004, the Baltimore City Health Department’s Staying Alive Drug Overdose Prevention and Response Program has trained more than 3,000

4. NC: Project Lazarus

Maryland’s Naloxone Law

1. Certificate and Training Entity

2. Self Identified Applicant for Training

3. Third Party Prescriber

4. A Dispensing Source

5. Reporting Requirements

6. Liability Issues

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Health-General Article,

Title 13, Subtitle 31,

Annotated Code of Maryland

Sections 13-3101 – 3109

Code of Maryland Regulations,

Title 10, Subtitle 17, Chapter 08,

Regulations .01-.11

Training/ Certifying Entity

The Department of Health and Mental Hygiene (the Department) may authorize private or public entities, including local health departments, HG §13-3101, to issue and renew certificates and conduct educational training programs. HG §13-3102(b)(2) & (b)(3).

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Eligible for Training & Certificate

Is at least 18 years old. HG §13–3104(b). Expects to have, as a result of his/her occupation

or volunteer work or family or social experience, the ability to assist an individual who is experiencing an opioid overdose. HG §13–3104(c); COMAR 10.47.08.05.B.(2).

Successfully completes an educational training program offered by an authorized entity. HG §13–3104(d)(1). Submits a completed application to the authorized entity on the form that the Department requires. HG §13–3105; COMAR 10.47.08.05.

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Obtaining a Prescription & Naloxone • Qualified trainees are entitled to receive a certificate.

• Show your certificate to get a prescription for naloxone from a physician or nurse practitioner (NP).

• A certificate is NOT a prescription

• Naloxone & delivery devices may be dispensed from:

• A pharmacy that stocks or can order naloxone

• An authorized training entity that dispenses naloxone

• A qualified health care provider, including:

• A physician or NP in private practice or at local health department

• A registered nurse (RN) at local health department with approval for nurse dispensing of naloxone.

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Third Party Prescribing & Dispensing

Physicians who prescribe and dispense naloxone in accordance with authorized entity protocols may not be subject to disciplinary action by the Maryland Board of Physicians solely for the act of dispensing (or prescribing) naloxone.

HG §13-3109. Physician dispensing is otherwise governed by Heath Occupations (HO) §12-102 and COMAR 10.13.01-.05.

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Certificate Holder’s Responsibilities

Certificates are valid for two years. Apply for renewal no later than 90 days before your certificate expires.

An entity may charge you a reasonable fee to replace a lost certificate; keep it in a safe place.

Administer naloxone in accordance with training procedures.

Make a good faith effort to get emergency medical help for the person experiencing an opioid overdose.

Please remember to contact the Poison Center or training entity after administering naloxone.

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DHMH May Suspend or Revoke a Certificate If:

A certificate holder improperly uses or administers naloxone, or DHMH determines it’s necessary in order to protect public health or safety.

The training entity doesn’t meet DHMH requirements or has issued someone an invalid certificate.

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Opioid user has a Prescriber Relationship?

No Yes

Certificate Holder (caregiver) Training taken at Worcester County Health Department

Narcan RX given by Health Department MD in Certificate

Holder’s Name

Pt Receives Narcan Prescription from own

Provider

Narcan Kit dispensed to Certificate Holder

Insurance Covers Narcan dispensed in Patient’s name from Pharmacy

Voucher for Narcan Kit

NALXONE RESCUE KIT

Prescribetoprevent.org

Screen HIGH RISK Patients

LOOK for med interactions – PDMP (Rx)or OTC-

Ask about mixed drugs to potentiate drug of choice

WARN of potential for accidental overdose with opioids when other medications are added, or switching opioid forms.

Offer addictions treatment programs, Naloxone training for family, caregivers at Health Department

Meds which increase opioid effect

Prescriptions OTC’s

All antipsychotics

Antidepressants

Blood pressure meds

Antibiotics (zithromax)

Benzo’s (valium etc)

Cholesterol meds

Other opioids (methadone, suboxone)

Stimulants (ritalin)

Cough/cold

Antihistamine/decongestants (Claritin-D)

Antacids (Prilosec)

Tylenol and Aleve

Tagamet HB (Cimetidine) is a broad CYP450 inhibitor. This basically means it 'clogs' the enzymes that metabolize opiates\opioids out of the body.

Quinine is an ingredient in tonic water, and inhibits the CYP450 set, more specifically, CYP2D6.

CYP2D6 is the MAIN enzyme for opiates like oxycodone, heroin, hydromorphone, etc.

White grapefruit juice contains three ingredients that clog the CYP450 set.

Dextromethorphan HBr, Robitussin, Zicam, etc. has a special effect in this formula.

contributes to analgesia and euphoria for all major opiates.

prevents build up of tolerance with opiates,

30mg of DXM a half hour before dosing will slow tolerance build up.

Good Samaritan Law H.B. 416 – Criminal Procedure – Limited Immunity – Alcohol- or Drug-Related Medical Emergencies Provides that a person who, in good faith, seeks, provides or assists with medical

assistance for another person experiencing an alcohol- or drug-related medical emergency shall be immune from prosecution for certain minor enumerated crimes, if the evidence for the criminal prosecution was obtained solely as a result of the person’s actions in rendering or obtaining aid for the victim. This immunity extends to the person who experiences the medical emergency.

Crimes included from the Code of Maryland, Criminal Law Article:

§5-601: possessing/administering a controlled dangerous substance (CDS);

§5-619: use of/intent to use drug paraphernalia;

§10-114: underage possession of alcohol;

§10-116: obtaining alcohol for underage consumption; and

§10-117: furnishing alcohol for underage consumption.

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