Development, implementation, and evaluation of a clinical decision support tool to improve naloxone coprescription within Military Health System pharmacies

Abstract

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To describe the development, implementation, and evaluation of a pharmacy clinical decision support tool designed to increase naloxone coprescription among people at risk for opioid overdose in a large healthcare system. Summary The Military Health System Opioid Registry and underlying presentation layer were used to develop a clinical decision support capability to improve naloxone coprescription at the pharmacy point of care. Pharmacy personnel use a patient identification card barcode scanner or manually enter a patient’s identification number to quickly visualize information on a patient’s risk for opioid overdose and medical history related to pain and, when appropriate, receive a recommendation to coprescribe naloxone. The tool was made available to military treatment facility pharmacy locations. An interactive dashboard was developed to support monitoring, utilization, and impact on naloxone coprescription to patients at risk for opioid overdose. Conclusion Initial implementation of the naloxone tool was slow from a lack of end-user awareness. Efforts to increase utilization were, in part, successful owing to a number of enterprise-wide educational initiatives. In early 2020, the naloxone tool was used in 15% of all opioid prescriptions dispensed at a military pharmacy. Data indicate that the frequency of naloxone coprescription to patients at risk for opioid overdose was significantly higher when the naloxone tool was used than when the tool was not used.

Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System

“…13 Within the MHS, the frequency of naloxone co-dispensing in individuals who met criteria for at least 1 of 4 risk indicators during the study period was 116 per 1000 individuals. Although our finding far exceeded previously published estimates in samples of Medicare Part D (4.6 per 1000) or commercially insured beneficiaries (5 per 1000), 14,31 the rate was still low. Predictive models based on the 2010-2018 data from several US Federal surveys projected a 15% reduction in opioid-related deaths if naloxone prescribing rates were to persist at current levels.…”

Naloxone prescribing practices in the Military Health System before and after policy implementation

“…As such, the differences in prescribing rates across the different risk indicators may reflect differences in programming, dissemination efforts, and utilization of decision support tools by pharmacists, relative to opioid prescribing providers. 14 Descriptively, naloxone prescribing rates for patients who met the criteria for LOT, elevated MEDD, and elevated RIOSORD exceeded 20% by the end of the study period, whereas naloxone prescribing rates for patients coprescribed benzodiazepines did not surpass 12%. During the Department of Defense OEND program implementation, some prescribers have questioned the utility of prescribing naloxone for patients who receive a 1-day supply of benzodiazepine that overlaps with a postprocedural opioid prescription (eg, refractory surgery and vasectomies).…”

“…As such, the differences in prescribing rates across the different risk indicators may reflect differences in programming, dissemination efforts, and utilization of decision support tools by pharmacists, relative to opioid prescribing providers. 14…”

“…17 To support policy implementation, additional clinical decision support tools (eg, Look-Up Tool) demonstrated some benefits in improving naloxone prescribing practices within military treatment facilities. 14…”

“…17 To support policy implementation, additional clinical decision support tools (eg, Look-Up Tool) demonstrated some benefits in improving naloxone prescribing practices within military treatment facilities. 14 However, the Department of Defense Opioid Overdose Education and Naloxone Distribution (OEND) train-the-trainer program and the public-facing web site were not disseminated until in mid-2020, more than 2 years after policy release. This OEND program was developed based on the successful Veterans Administration's OEND program 9 and tailored for the Military Health System through a multiyear 2-phase implementation science approach.…”