Gov. Pat McCrory signs the naloxone standing order bill at a press conference held in the Guilford County Sheriff’s Office in mid-June.
Gov. Pat McCrory signs the naloxone standing order bill at a press conference held in the Guilford County Sheriff’s Office in mid-June. Photo courtesy: NC DHHS

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<p>North Carolina became the third state in the nation with a standing order to allow pharmacists to give naloxone to people without a doctor’s prescription.

By Minali Nigam

In 2014, nearly 1,200 people in North Carolina died from accidental opioid drug overdoses.

Every one of them could still be alive today, said Rick Brajer, Health and Human Services secretary, if they had had access to something to reverse their overdoses.

That’s why Gov. Pat McCrory signed a bill last month that would let people at risk for opioid addiction or overdose get their hands on naloxone without a prescription from their doctors. The bill also allows access to the drug for people who know someone at risk of overdose, like a family member or a friend.

Naloxone is a drug that blocks the action of opioids, which are strong pain medications.

Gov. Pat McCrory signs the naloxone standing order bill at a press conference held in the Guilford County Sheriff’s Office in mid-June while legislators, EMS personnel and state health officials look on. Photo courtesy: NC DHHS

“If someone has already overdosed it can actually displace opioids from those receptors and it can reverse respiratory depression [suppressed breathing],” said Theo Pikoulas, associate director of Behavioral Health Pharmacy Programs for Community Care of North Carolina.

In 2013, McCrory had signed the Good Samaritan Law, which permits emergency responders to carry and use naloxone. The law was expanded in August 2015 to allow pharmacists to distribute naloxone to someone with a doctor’s prescription. http://www.ncleg.net/Sessions/2015/Bills/Senate/PDF/S154v5.pdf

“We’ve gone one step further with the legislation that allows a statewide standing order for pharmacists,” Pikoulas said.

Essentially, that means anyone in North Carolina has had the prescription written for them in advance by the state health director.

‘Proactive’ pharmacists

Randall Williams, the person in that role, said anyone can walk into a pharmacy and request naloxone, but pharmacists can decide whether to give it to them based on criteria outlined in the standing order.

Contents of a naloxone reversal kit distributed by the NC Harm Reduction Coalition. Photo credit: Rose Hoban

“What we don’t want to have happen, which we don’t think will happen, is for people just to go in and ask for it for no reason,” he said.

With the standing order, pharmacists can give one of two forms of naloxone, said Vera Reinstein, network pharmacist for Northern Piedmont Community Care. Those forms are intranasal, to be sprayed up the nose, or intramuscular, which needs to be injected with a needle long enough to reach a muscle.

“There are two products of the intranasal. One is the branded nasal Narcan that was just released to the market this winter. The other is a generic intranasal naloxone,” Reinstein said.

The generic intranasal requires a lot of equipment assembly, she said. The Narcan is more convenient because you can just “peel it, open it and spray it.”

While chain pharmacies including CVS and Walgreens have their own standing orders for naloxone, Williams said, they will be switching over to the state’s order in upcoming months.

However, Reinstein said she’d received a call from Walmart to say their stores wouldn’t be participating in the statewide standing order yet. She said she didn’t know why.

Alice Dillard, who works at Triangle Pharmacy in Durham, said pharmacists make a difference in a patient’s life by working with care managers and initiating conversations about medications like naloxone.

“If it’s already one of my patients, we can look and see if are they taking opioids in high doses, “ Dillard said. “You can see right there, there’s a patient who would qualify for [naloxone].”

“It’s great that pharmacists are able to be proactive and look out for people who might be at risk for overdoses,” Pikoulas said.

Pharmacists participating in the standing order are encouraged, but not required, to register on the North Carolina Division of Public Health’s educational website about naloxone, Williams said.

“They do not have to sign up,” he said, “If you are a licensed pharmacist in North Carolina you can dispense this drug, period.”

Costs and coverage

“A lot of people don’t realize how high their risk is with certain opioids,” Reinstein said. “They feel like, ‘Well, if I got a prescription legitimately from a provider and I legitimately have pain,’ they don’t really think of that as a dangerous medication.”

“And that’s why most of the unintentional overdoses, a lot of overdoses are with prescription opioids.”

Alice Dillard said she hasn’t received any requests from patients for naloxone yet, but thinks family members or people who know someone at risk will be more likely to ask for it than an addict.

“The only real quandary is about billing someone’s insurance,” she said. “If it’s not for you, I can’t bill it to your insurance.”

Medicaid will cover everything in the standing order, according to Dillard. Otherwise, it depends on specific insurance plans.

“The insurance is not part of this standing order,” Reinstein said. “The standing order really just addresses the medical or prescribing aspect of it.”

Most people who are buying naloxone for someone else, Reinstein said, would probably pay in cash.

For people without insurance, the generic intramuscular is the least expensive version, estimated at $20, according to Reinstein. The generic intranasal form could cost between $60 and $100, she said, while branded Narcan would probably cost between $150 and $180.

“I had somebody that we ordered [naloxone] for not long ago and she decided not to get it because of the cost,” said Dillard.

Ultimately, the standing order increases the availability of naloxone and helps save lives, McCrory said at a June press conference and bill signing.

“Clearly the intent is to break down all barriers to people getting the drug for loved ones, family, for people they’re concerned about,” Williams said.

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