Implementation of a Sustainable Naloxone Service in Community Pharmacy Coordinated Through the Medium of Pharmacy Students Trained in Advanced Opioid Stewardship By: Bethany Volkmar, PharmD Candidate Introduction According to the North Carolina Office of The Chief Medical Examiner, suspected overdose deaths in North Carolina reached 4,243 in 2022, up from 3,961 deaths in 2021.1 Between October 2021 and September 2022, fentanyl-positive overdose deaths reached 2,539, emphasizing the need for opioid harm reduction strategies to be implemented into the healthcare system2 With pharmacists being one of the most accessible healthcare providers, especially in rural North Carolina communities, counseling and dispensing of naloxone in community pharmacies has the potential to make a significant impact on reversing the increasing number of opioid overdose death trends we have seen over the last few years. In North Carolina, any pharmacist practicing in the state and licensed with the NC Board of Pharmacy can dispense naloxone to persons under the State’s Standing Order.3 This includes persons who may need it for themselves, those who need it
for family members or friends, or those who may need it to assist another person at risk of experiencing an opioid overdose. A list of approved products for dispensing under the standing order includes naloxone nasal spray, intranasal syringes, injectable vials/syringes, and prefilled injectors.4
While several barriers exist to increasing naloxone distribution in the pharmacy setting, identifying patients at the highest risk and in need of naloxone is often considered by pharmacists as one of the biggest obstacles. The validated screening tools considered most favorable among pharmacists in streamlining the assessment of high-risk patients include the North Carolina Controlled Substances Reporting System’s Overdose Risk Score (ORS) and the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) screening tool. The Overdose Risk Score (ORS) available in the North Carolina Controlled Substances Reporting System (NC CSRS) stratifies a Page 12
patient’s risk of overdose based on the number of prescribers, number of pharmacies, morphine equivalent dose, and overlapping prescriptions in a patient’s controlled substance fill history.5 Scores range from 0-999, with higher numbers indicating an increased risk of unintentional overdose. Most importantly, pharmacists can access the CSRS to view an ORS score within seconds. Any score above 450 indicates an elevated risk of unintentional overdose and a need for naloxone.5 The Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD) is a 17-item validated screen pharmacists can use independently or as a complement to the CSRS when the ORS score falls below 450.6 Unlike the ORS, the RIOSORD accounts for other relevant factors contributing to overdoses, such as conditions known to compromise pulmonary function, other mental health conditions, and concomitant use of medications known to cause drug accumulation and toxicity resulting from impaired opioid