Every generation struggles with their own set of public health issues. Our generation is faced with the opioid epidemic–which has been brewing for over 20 years. A closer look into the past few decades reveal a staggering trend: levels of prescription opioid use grew exponentially from 1999 to 2014, although there was no overall change in the amount of pain that Americans reported. In light of unprecedented overdose rates, President Trump has declared the issue a public health emergency.
For reducing overdose deaths, widespread distribution of naloxone–an overdose medication used to block or reverse the effects of opioid drugs–remains the primary measure that can help immediately. Moreover, nearly every state has modified relevant laws and regulations to encourage standing orders for naloxone. Through these standing orders, states have essentially designated a prescription for naloxone to all of their citizens.
This means that pharmacists are now clear stakeholders. They have the clinical responsibility to dispense this life-saving drug and provide patient education about its use. However, widespread distribution of naloxone has been hampered by pharmacists’ misconceptions about criminal liability.
The Laws are Wordy
A lengthy conversation with a colleague, who is a pharmacist at an independent pharmacy, brought to light a dilemma she struggles with quite often: opting out of dispensing naloxone because she’s unfamiliar with the legislation that allows it. Uncertainty about the potential criminal liability associated with dispensing naloxone keeps her–and many pharmacists across the country–on the sidelines of our nation’s fight against overdose deaths.
In fact, there has been a recent wave of legal innovations designed to dispel common concerns about legal risks associated with dispensing naloxone. Most notably, nearly all states have provided legal protection for naloxone prescribing, dispensing, and administration. Furthermore, 31 states have provided additional criminal immunity for pharmacists who dispense naloxone by prohibiting disciplinary action by state entities.
These policy changes have not been enough to build confidence among pharmacists in the field. With its numerous pages of sometimes dense statistics and legislative jargon, nobody would mistake a policy on dispensing naloxone for a beach read–especially when their professional license is at stake. Here’s a link to Pennsylvania’s policy on overdose response immunity, a good example of what pharmacists are expected to decipher.
Not a Single Lawsuit About Dispensing Naloxone
To get a better understanding of the legal risk associated with dispensing naloxone, I spoke with a policy advisor from the New York City Department of Health & Mental Hygiene. Much of our conversation was on the risk of harm associated with naloxone. She emphasized that naloxone has no potential for abuse and a minuscule risk of severe adverse reactions. Because harm to the patient is a necessary component of a successful lawsuit, this translates into a low risk of civil liability for pharmacists dispensing naloxone.
Furthermore, she highlighted a 2015 review that failed to find a single lawsuit associated with dispensing naloxone in the United States.
Pharmacists Are Overall Unfamiliar with Substance Use Disorders
Perhaps some of pharmacists’ unease about naloxone stems from too little education about substance use disorders (SUDs) in general. It is more important than ever for students to arrive in the professional world well-versed in the arena of SUDs, but overall, schools of pharmacy in the United States devote little didactic or experiential time to developing student competency in this area. As a recent graduate, I still have access to the advanced pharmacy practice portal at St. John’s University. Of the hundreds of rotations available to students, there are only a handful of electives dedicated to SUDs. Notably, St. John’s is nestled in the middle of New York City, where you would imagine students should have numerous opportunities to learn about SUDs.
In short: you can’t expect students to graduate with competence in naloxone protocols if they’re never exposed to it during school.
There have been recent strides taken by the American Association of Colleges of Pharmacy (AACP) to update their curricular guidelines to include topics of SUDs. The AACP’s new curricular guidelines recommend that students be provided with both mandatory and elective opportunities to learn about SUDs. These guidelines include didactic requirements centered around naloxone dispensing, administration, and counseling. By following this recommendation, pharmacy schools will begin to manufacture graduates who are ready to take action on the front lines of the opioid crisis.
No Need for Hesitation
The current opioid epidemic is the deadliest drug crisis in American history. How bad is it? Overdoses, fueled by opioids, killed more people last year than guns or car accidents. Pharmacists find themselves at the forefront of managing the epidemic, serving as the gatekeepers for life saving overdose antidotes. However, up to this point, we have expressed a timid attitude towards dispensing naloxone.
When a patient is at risk of overdose, ensuring that the patient receives naloxone is an integral component of our nation’s multi-pronged approach to end the opioid epidemic. Pharmacists should have no hesitation about offering naloxone to patients because of potential legal concerns.
Omar Rahman, PharmD is an MPH candidate at the University of Pittsburgh Graduate School of Public Health. He is working with IRETA on several projects related to substance use, addiction, and recovery.