The Works Naloxone Hydrochloride Dispensing

PROCEDURE

The Works Naloxone Hydrochloride Dispensing

Policy Mgmt #: Information Management Services will Input.

Version: 2.00

Date Approved: February 23, 2017

GENERAL INFORMATION

Content Summary

Dates

People

Revision History

Approvals/ Approval process

1. PURPOSE

To provide guidelines for The Works’ staff to dispense naloxone and train Prevent Overdose in Toronto (POINT) clients to safely administer naloxone in the event of opioid overdose

1. RELATED POLICY DOCUMENTS

Medical Directives

1. Treatment of Anaphylaxis and Severe Medical Events (CDC Cross Cutting)

Policies

The Works Naloxone Dispensing Policy

(INSERT URL WHEN AVAILABLE)

Medication Incidents Policy (TPH Cross Cutting)

Procedures

Medication Incidents Procedure (TPH Cross Cutting)

The Works Medication Storage Policy

\\Vs-160-hlhdata\hlhdata\HLH\HLH\Needle Exchange\Policies and Procedures\Medication Admin. Medical Directives and Policies and Procedures\Medication Storage Policy.docx

Practice Standards and Guidelines

1. CNO Practice Standard: Confidentiality and Privacy – Personal Health Information, Updated 2009

2. CNO Practice Standard: Consent, Updated 2013

3. CNO Practice Standard: Documentation, Updated 2008

4. CNO Practice Standard: Medication, Updated 2014

1. PROCEDURE

A. Screening Practice:

• All Works clients will be screened for naloxone kit eligibility at every opportunity(ie. when attending for harm reduction supplies, methadone clinic, blood testing, vaccination, other nursing services, and counseling) and at all venues (van, outreach, fixed site, etc.)
• All clients will be screened for contraindications and precautions
• An Overdose History Form will be completed by program staff, for each client
• Clients who are friends or family of people who use opioids or other drugs suspected/known to be cut with opioids, will be encouraged to use the Ontario Naloxone Pharmacy Program (ONPP)for naloxone kits unless they are not willing to do so or not willing or able to present their Ontario Health Insurance Plan(OHIP) card as required by the ONPP.

B. Assessment for abbreviated point training eligibility:

In recognition of the potentially chaotic circumstances and competing priorities of some Works clients, an abbreviated version of the standard POINT curriculum can be offered. Staff must use professionaljudgment to evaluate the risks of a client not receiving naloxone against the risks of not receiving standard POINT training. In conjunction with this evaluation, brief POINT training may be provided to eligible clients who:

• Express not having the time to complete full POINT training, or
• Express being time constrained due to imminent substance use, or
• Express having, or by staff assessment present as having, cognitive or literacy challenges limiting ability to participate in full POINT training

C. POINT Training:

Certified staff will provide training to the client on all components of the POINT Naloxone and Overdose Training Guide:

• Naloxone information and pharmacology
• Overdose prevention strategies
• Recognizing signs and symptoms of overdose
• POINT response protocol: stimulating overdose victim; calling 911; naloxone administration; chest compressions and/or rescue breathing; evaluation of resuscitation intervention and administration of additional naloxonedose
• Interfacing with paramedics and police
• Naloxone administration
• Chest compressions
• Post-overdose follow-up and care
• Overdose response without naloxone
• Overdose response myths
• Post-overdose debriefing
• Naloxone administration evaluation
• Naloxone care and review of expiry date
• Naloxone refill procedure

Note: Staff will train clients to administer chest compression-only CPR following naloxone administration. Rescue breathing is considered an adjunct or alternative to the resuscitation protocol for clients who are competent in and willing to include rescue breathing in their opioid overdose response.

Upon completion of the training, staff will assess and ensure the client's understanding of the curriculum through verbal or written recall and accurate demonstration of practical skills.

D. Abbreviated POINT Training:

Certified staff will provide training to the client on select components of the POINT Naloxone and Overdose Training Guide. At minimum, this will include:

• What is an overdose?
• Naloxone: onset, duration, effect

• Risk factors
• Recognizing signs and symptoms of opioid overdose
• POINT response protocol
• Aftercare
• Naloxone care and review of expiry date

E. POINT Retraining:

Certified Staff will retrain POINT clients on all or select components of the POINT Naloxone and Overdose Training Guide as requested by client and/or when a client presents for a refill.

F. Naloxone Dispensing:

The standard dispensing practice under the POINT program is 1 POINT Kit with 2 naloxone nasal spray devices. However, there are circumstances whereby staff are permitted to dispense multiple POINT Kits to one client. A client is eligible to receive more than 1 POINT kit if they:

1. engage in a high opioid use environment (eg. lives in a community or amongst a group of people where frequent opioid use occurs)
2. have responded to multiple overdoses in the previous 3 months
3. use known, or suspected, high potency opioids (eg. fentanyl, heroin as per alerts)
4. report barriers to accessing The Works for refills in a timely manner
5. have a history of frequent naloxone refills
6. request multiple POINT kits based any of the reasons above

For clients dispensed more than one POINT kit, staff will put added emphasis on the importance of client's following-up after naloxone administration. Clients will be asked not to distribute their POINT kits to others and will be provided with POINT promotional material to encourage their peers to seek out their own POINT training and kit.

i) Initial Dispensing

Naloxone dispensing will follow POINT training for eligible clients. Using the Overdose History Form and Naloxone Knowledge Checklist and Order to Dispense Formstaff will:

• Insert a check mark, indicating the client's understanding beside each component of the overdose training
• Indicate if the client received an abbreviated POINT training
• Fill out the client's name and date of birth, naloxone lot numbers(s) & expiry date(s)
• Sign (including designation as appropriate) and date form

• Ensure the POINT Kit contains all necessary contents
• Check expiry of naloxone and ensure that there is at least 6 months remaining on the nasal spray devices
• Complete the Naloxone Certification Card
• Complete the medication label(s) on packaged naloxone with date, client name, staff name, and expiry date
• Dispense 1 POINT Kit to the client initially or up to 5 POINT Kits as indicated by assessment

ii) Refill Dispensing

Lost, stolen, confiscated, expired and administered naloxone will be replaced. Staff will:

• Refer to the Naloxone Prescription Database spreadsheet to verify prior POINT training and initial dispensing
• Offer and provide as needed, retraining on all or part of the POINT training
• Complete Knowledge Checklist andOrder to Dispense Form as stipulated above

• Ensure that the POINT Kit contains all necessary contents
• Check expiry date of naloxone and ensure that there is at least 6 months remaining on the nasal spraydevices
• Complete the Naloxone Certification Card
• Complete the medication label(s) on packaged naloxonewith date, client name, staff name, and expiry date
• When presenting for a refill, dispense 1 POINT Kit, or individual components of the POINT Kit as requested by client, or multiple POINT Kits as indicated by assessment

Note: To safely dispense naloxone, staff must verify drug name and expiry date of the naloxone.

G. Monitoring and Follow-Up:

When a client presents in person or by phone to report a naloxone administration event, Works staff will:

• Provide an opportunity for the client to debrief the experience
• Complete the Naloxone Administration Evaluation Form
• Assess the client's POINT training recall and provide re-training as indicated
• Dispense a refill POINT kit or multiple kits as indicated

Staff members who facilitate this monitoring and follow-up process are tooffer clients counselling and referrals as needed.

H. Naloxone Disposal:

Returned expired Naloxone will be disposed as per the Naloxone Inventory Policy.

I. Documentation:

Certified staff will give all completed forms (Overdose History form and Naloxone Knowledge Checklist and Order to Dispense, and Naloxone Administration Evaluation) to Support Assistant staff for entry into the confidential Naloxone Prescription Database. Following data entry, these forms will be placed in a locked cabinet and filed under the client's name as appropriate.

J. Procedure for packaging POINT Kits:

All POINT kits will include:

• 2 x 0.1mL nasal spray devices of 4mg naloxone hydrochloride, 40mg/mL, packaged and labeled
• Naloxone Kit Insert (Step by step instruction pamphlet for administration of naloxone nasal spray)
• Naloxone Certification Card
• Narcan Nasal Spray product monograph (French and English)
• 1 pair of non-latex gloves
• 1 rescue breathing barrier
• 1 hard case

Naloxone nasal sprayswill be packaged with a label displaying the following information in accordance to principles of safe medication administration:

• client’s name
• dispensing date
• name of the medication: naloxone
• strength of the medication: 40mg/mL
• dose, route of administration and frequency: 0.1mL (single spray) in the nostril, every 2-3 minutes in alternate nostril as needed
• quantity of medication dispensed: 2 naloxone nasal spray devices per unit expiry date
• storage instructions: protected from sunlight and stored at 15 - 25C
• thedispenser's name, title, business address and phone number

POINT Kits will be stored in a locked cabinet at The Works. All naloxone (and supplementary kit supplies) will be inventoried and accounted for as per The Works Medication and Storage Handling Policy and Procedure.

d) Documentation required:

For each client being dispensed naloxone initially or as a refill, staff must complete:

• Overdose History Form

• Naloxone Knowledge Checklist and Order to Dispense Form
• Naloxone Certification Card

For each naloxone use reported, staff must complete:

• Naloxone Administration Evaluation form

1. FORMS AND/OR TEMPLATES

POINT Naloxone and Overdose Training Guide

Overdose History Form

Naloxone Knowledge Checklist and Order to Dispense Form

Naloxone Administration Form

Naloxone Kit Insert

Naloxone Certification Card

Naloxone Inventory Form

Staff POINT Competency Checklist

POINT Certificate of Competence

Naloxone Prescription Database

1. REFERENCES/SOURCES

Adapt Pharma. (2015). Narcan nasal spray full prescribing information. Retrieved January 2017 from:

Behar, E. et al. (2015). Brief overdose education is sufficient for naloxone distribution to opioid users. Drug and Alcohol Depend. (2015),

British Columbia Centre for Disease Control. (2015). BCCDC Non-certified practice decision support tool: dispensing Naloxone. Accessed April 16, 2015:

Centre for Addiction and Mental Health. (2012). Buprenorphine/Naloxone for opioid dependence: clinical practice guideline. Accessed February 9, 2015:

College of Physicians and Surgeons. (Sept 2012). Policy Statement #5-12: Delegation of Controlled Acts. Retrieved from

Drug Overdose Prevention and Education Project. (2014). Quick Narcan Training Checklist. San Francisco, CA: Eliza Wheeler.

Health Canada (2016). Drugs and Health Products Notice: Prescription Drug List (PDL): Naloxone. Accessed August 5, 2016:

Ministry and Health and Long Term Care (2016). News Release: Naloxone Now Available Without a Prescription in Ontario Pharmacies. Accessed August 5, 2016:

Ministry of Health and Long Term Care, Ontario Public Drugs Program (2016). Ontario Naloxone Pharmacy Program description. Accessed August 5, 2016:

Naloxone Hydrochloride Injection USP Product Monograph November 4, 2011.

New York State Department of Health (2016). Technical working group on resuscitation training in naloxone provision programs, 2016 report. Accessed August 12, 2016:

World Health Organization (2014). Information sheet on opioid overdose. Accessed May 21, 2015: