Faculty Bibliography

BACKGROUND:Overdose from opioids is a serious public health and clinical concern. Veterans are at increased risk for opioid overdose compared with the civilian population, suggesting the need for enhanced efforts to address overdose prevention in Department of Veterans Affairs (VA) health care settings, such as primary care clinics. METHODS:Prescribing providers (N = 45) completed surveys on baseline knowledge and concerns about the VA Overdose Education and Naloxone Distribution (OEND) initiative prior to attending an OEND educational training. RESULTS:Survey items were grouped into 4 OEND-related categories, reflecting (1) lack of knowledge/familiarity/comfort; (2) concerns about iatrogenic effects; (3) concerns about impressions of unsafe opioid prescribing; and (4) concerns about risks of naloxone prescribing. Although certain OEND-related categories were associated with each other, concerns related to iatrogenic effects of OEND (e.g., patients will use more opioids and/or be less likely to see treatment) and lack of knowledge/familiarity/comfort with OEND were endorsed more than concerns related to giving impressions of unsafe opioid prescribing. The majority of providers endorsed the belief that those prescribing opioids to patients should be responsible for providing overdose education to those patients. System-wide naloxone prescription rates and sources increased over 320% following initiation of OEND expansion efforts, although these increases cannot be viewed as a direct result of the in-service trainings. CONCLUSIONS:Findings demonstrate that some providers believe they lack knowledge of opioid overdose prevention techniques and hold concerns about OEND implementation. More training of medical providers outside substance use treatment settings is needed, with particular attention to concerns about harmful consequences resulting from the receipt of naloxone.

Despite shifts in rhetoric and some positive movement, Americans with the disease of addiction are still often stigmatized, criminalized, and denied access to evidencebased care. Dramatically reducing the number of lives unnecessarily lost to overdose requires an evidence-based, equity-focused, well-funded, and coordinated response. We present in this brief article evidence-based and promising practices for improving and refocusing the response to this simmering public health crisis. Topics covered include improving clinical decision-making, improving access to non-judgmental evidence-based treatment, investing in comprehensive public health approaches to problematic drug use, and changing the way law enforcement actors interact with people who use drugs.

OBJECTIVES/OBJECTIVE:The opioid overdose epidemic continues to claim the lives of tens of thousands of Americans every year. Increased access to the opioid antagonist naloxone can reduce opioid-related morbidity and mortality. In this commentary, we describe several recent legal innovations designed to encourage pharmacists to ensure that naloxone is available when and where it is needed, and dispel some common misconceptions regarding potential legal risks associated with pharmacy naloxone dispensing. DATA SOURCES/METHODS:Data are drawn from state laws and regulations, as catalogued by the Westlaw database. SUMMARY/CONCLUSIONS:States have rapidly modified law and policy to increase layperson access to naloxone. As of August 2016, 44 states permit naloxone to be prescribed for administration to a person with whom the prescriber does not have a prescriber-patient relationship. Forty-two states permit naloxone to be dispensed via a non-patient-specific mechanism such as a standing or protocol order, and 5 states permit some pharmacists to prescribe naloxone on their own authority. The liability risk associated with naloxone dispensing is no higher than any other medication, and may be lower than some. However, to encourage the prescription and dispensing of naloxone, 36 states provide additional protection from civil liability for pharmacy naloxone dispensing, and 32 states provide protection from potential criminal action. Naloxone access laws in 31 states explicitly provide that dispensing naloxone as permitted by law cannot be grounds for disciplinary action by the state board of pharmacy or similar entity. CONCLUSION/CONCLUSIONS:Pharmacists are key members of the health care team and are uniquely situated to reduce potential opioid overdose risk. Pharmacists should be aware of and utilize innovative state laws designed to increase access to naloxone.

The opioid overdose epidemic claims the lives of tens of thousands of Americans every year. Opioid overdose is reversible by the administration of naloxone, a pure antagonist now available in formulations specifically designed and labeled for layperson use. Despite broad support for layperson access to naloxone from professional organizations, health officials, and clinical experts, qualitative studies suggest that some providers have concerns about legal risks associated with naloxone prescribing, particularly co-prescribing naloxone to pain patients. Such concerns are unfounded. The legal risk associated with prescribing naloxone is no higher than that associated with any other medication and is lower than many. Additionally, laws in a majority of states provide explicit legal protections for providers who prescribe or dispense naloxone, in many cases extending this protection to prescriptions issued to friends, family members, and others. In this large and increasing number of states, the liability risk of prescribing or dispensing naloxone in good faith to a patient at risk of overdose (or, in states where such prescribing is permitted, to an associate of such a patient) is either extremely low or absent entirely. Where a prescriber determines, in his or her clinical judgment, that a patient is at risk of overdose, co-prescribing naloxone is a reasonable and prudent clinical and legal decision. No clinician should fail or refuse to issue such a prescription based on liability concerns.

In March of 2015, the United States Department of Health and Human Services identified 3 priority areas to reduce opioid use disorders and overdose, which are as follows: opioid-prescribing practices; expanded use and distribution of naloxone; and expansion of medication-assisted treatment. In this narrative review of overdose prevention and the role of prescribers and pharmacists in distributing naloxone, we address these priority areas and present a clinical scenario within the review involving a pharmacist, a patient with chronic pain and anxiety, and a primary care physician. We also discuss current laws related to naloxone prescribing and dispensing. This review was adapted from the Prescribe to Prevent online continuing medical education module created for prescribers and pharmacists (http://www.opioidprescribing.com/naloxone_module_1-landing).

Fatal opioid overdose, the leading cause of injury death in the USA, is regularly described as an epidemic. The response to the overdose crisis, however, has largely failed to utilise many of the public health tools that have proven effective in combating epidemics. Chief among these is the systematic and timely use of data by public health officials to track outbreaks and effectively target interventions. This failure is particularly acute regarding data from prescription monitoring programmes, which are routinely used by clinicians and law enforcement agents, but often unavailable to health officials. We argue for a shift in emphasis and resources towards an evidence-based public health approach to data use for overdose prevention. [Davis CS, Green TC, Zaller ND. Addressing the overdose epidemic requires timely access to data to guide interventions. Drug Alcohol Rev 2016;35:383-386].

BACKGROUND:The opioid overdose epidemic in the United States is driven in large part by inappropriate opioid prescribing. Although most American physicians receive little or no training during medical school regarding evidence-based prescribing, substance use disorders, and pain management, some states require continuing medical education (CME) on these topics. We report the results of a systematic legal analysis of such requirements, together with recommendations for improved physician training. METHODS:To determine the presence and characteristics of CME requirements in the United States, we systematically collected, reviewed, and coded all laws that require such education as a condition of obtaining or renewing a license to practice medicine. Laws or regulations that mandate one-time or ongoing training in topics designed to reduce overdose risk were further characterized using an iterative protocol RESULTS:Only five states require all or nearly all physicians to obtain CME on topics such as pain management and controlled substance prescribing, and fewer than half require any physicians to obtain such training. CONCLUSIONS:While not a replacement for improved education in medical school and post-graduate clinical training, evidence-based CME can help improve provider knowledge and practice. Requiring physicians to obtain CME that accurately presents evidence regarding opioid prescribing and related topics may help reduce opioid-related morbidity and mortality. States and the federal government should also strongly consider requiring such training in medical school and residency.

Recently, an extensive study of 2,748 polar bears (Ursus maritimus) from across their circumpolar range was published in PLOS ONE, which used microsatellites and mitochondrial haplotypes to apparently show altered population structure and a dramatic change in directional gene flow towards the Canadian Archipelago-an area believed to be a future refugium for polar bears as their southernmost habitats decline under climate change. Although this study represents a major international collaborative effort and promised to be a baseline for future genetics work, methodological shortcomings and errors of interpretation undermine some of the study's main conclusions. Here, we present a reanalysis of this data in which we address some of these issues, including: (1) highly unbalanced sample sizes and large amounts of systematically missing data; (2) incorrect calculation of FST and of significance levels; (3) misleading estimates of recent gene flow resulting from non-convergence of the program BayesAss. In contrast to the original findings, in our reanalysis we find six genetic clusters of polar bears worldwide: the Hudson Bay Complex, the Western and Eastern Canadian Arctic Archipelago, the Western and Eastern Polar Basin, and-importantly-we reconfirm the presence of a unique and possibly endangered cluster of bears in Norwegian Bay near Canada's expected last sea-ice refugium. Although polar bears' abundance, distribution, and population structure will certainly be negatively affected by ongoing-and increasingly rapid-loss of Arctic sea ice, these genetic data provide no evidence of strong directional gene flow in response to recent climate change.