Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk episode 51 I'm your co host, Dr. Kane. I'm Dr Unknown Speaker 00:35 Schuman, and I'm Dr. Patel, and Speaker 1 00:37 so for today, actually, I'm excited to introduce the topic today. So this is pharmacist to the rescue. What do you mean? Pharmacist to the rescue? All right, so again, what we're gonna be talking about today is we're gonna be looking at the use of the Naloxone kits or the Naloxone injector Speaker 2 00:52 devices. So what are we rescuing patients from? Speaker 1 00:55 It's a great question. So what we're looking at is potentially a way of stemming some of the recent opioid epidemic that's been going on, we know that within the last few years, there's a rise in some of the either accidental or intentional overdoses of it, both from use of heroin as well as looking at prescription opioids, it's been something that's been coming at a number of states, especially hit hard on the East Coast, cities like Boston, Philadelphia and in even Chicago and even in the surrounding Lake County as well, there have been a number of these overdoses. And so out of that, it's become a public health crisis, essentially. And the use of these Naloxone kits, or use of naloxone as a as a way of reversing some of those effects of opioids and essentially preventing some of these deaths. Dr. Sean Kane 01:40 So Dr. Schuman, we use Naloxone on the inpatient side. I'm pretty familiar with it. I know it's been around a long time. Sounds like there's a kit available. Is that what's new in terms of what's hot with Naloxone, or is there something on top of that that's new and Speaker 1 01:53 exciting, right? So actually, a kit's probably no longer the term I should be using. Really, it's 'device', because what we have now are two of these proprietary new technologies. So previously, they were kits when somebody would be sent home, and for example, if they had a history of opioid use or was considered to be at risk for an overdose, you'd be given a kit. And usually these kits came in a little rubberized bag with a zipper on it, and inside would be little vials of naloxone, and either a syringe and a needle, or they would have a little nasal atomizer device, and so you'd be able to use those, and the individual would put them together. Speaker 2 02:33 We're going to talk a little bit more about the different products themselves, but seems like there are different ways that you can administer Naloxone, right? Speaker 1 02:40 So those, those earlier ones, were a little bit tricky to use. So what they found is these, these devices, were somewhat difficult to use, and so individuals who were in the heat of a moment and witnessing somebody having an overdose would have difficulty putting them together. There was also concern about accidental needle stick sticks with the needles, things of that. So it came out that we're looking at new devices that would all be put together already. And so the first one that came out was the Naloxone kit, or the Evzio autoinjector, and then the second one that recently came out was a Naloxone spray that's in a premeasured device. Dr. Sean Kane 03:15 So Dr. Schuman, I accept the fact that we have new, cool ways to give Naloxone to these high risk patients, but the title of the podcast was pharmacist to the rescue. So how is a pharmacist playing a role, given that we have these new products, Speaker 2 03:29 I love how pharmacists are incorporated in this new initiative that is going around to reduce the deaths due to opioid overdose, intentional or recreational use of opioids, and what's new and upcoming to and curtail or curtail this epidemic is different. Pharmacists Association, along with the state legislators, are coming up with new laws or regulations to allow pharmacists to either dispense the Naloxone or actually administer in some states, even the Naloxone to the patient under a standing order. Now, the definition of standing order versus collaborative agreement is different per state to state, but that's actually been the new updates across the country in itself. Speaker 1 04:16 Yeah, this was especially new as recently as summer of 2015 this was something that was passed in Illinois so that it is actually amended the Pharmacy Practice Act of Illinois to say that, Hey, as long as there is a standard procedure or protocol in place, a pharmacist may make the decision to look at an individual, assess them as they come through the pharmacy and determine whether or not there is that risk of overdose, regardless of whether it's from prescription or illicit drug use, and say, I think there's a risk here. I'm going to give you the kit or the device now, and I'm going to do the counseling on it as well as not just how to use it, but the signs and symptoms of overdose and all those pieces of and that was something, again, that was the law was officially passed in September of of 2015 and. In Illinois joined a number of other states who are in the process and others that are continuing on it. Dr. Sean Kane 05:04 So just so I understand this, what you're saying is that, depending on the state, if there is a standing order or a collaborative practice agreement, the pharmacist can dispense a Naloxone device or kit without having a prescription for that particular patient, absolutely. Speaker 2 05:20 And that is correct. And some of the states also have, like, a blank standing order ready to go. So if you are collaborating with a doctor in the community who's ready to sign that standing order, under that doctor's authority, you're allowed to dispense Naloxone kits to the patients. Dr. Sean Kane 05:38 And I know that we're not talking so much about administration on behalf of the pharmacist administering it. I know that you said that sometimes that is happening, but this almost is analogous to some of the vaccination efforts, in terms of, you don't have to have a prescription to give the influenza vaccine, for example. I assume that's more on the order of a standing order. That is correct, yeah. Speaker 1 05:59 So what they've done is, again, this establishment, because, again, this is a, this is a new step to really get this medication into the hands of at-risk individuals, but to make sure that it is standardized, there's a training program, and it specifically says a pharmacist shall complete a training program that's been approved by the Department of Human Services that goes through how to do it. It's a joint venture between the Illinois Department of Public Health, Department of Human Services, and related professional resources, and they can give it not just to the individual who's at risk themselves, but also to concerned entities. So if you're a family member who's concerned, or a nurse, a first responder, or another individual, any one of these entities could potentially receive the kit and the counseling on it. Speaker 2 06:47 And it makes sense to be able to give these kits to the concerned family members, per se, because you know, if the patient, it's him or herself, is overdosing, they're not going to be in any position to even administer this antidote. So counseling to the patient's caregiver or a family member who's concerned or a friend is actually what probably would be occurring in most instances. Dr. Sean Kane 07:11 So again, I just want to get this straight here. If Dr. Schuman is my friend and he's a heroin abuser, I can walk into a pharmacy in the state of Illinois with no prescription, and he doesn't have a prescription for his heroin, and I can get a Naloxone kit for him without a prescription from a healthcare provider. Speaker 2 07:30 So in the act that's written for Illinois, it says you you don't have to have a patient's chart in front of you showing opioid prescriptions filled or anything like that. In the pharmacist's good judgment, if somebody shows up at the desk and in a concerned individual for a friend or a family member, and there is a history of heroin use, then you can go ahead and administer the Naloxone antidote. Dr. Sean Kane 07:53 So to encourage the listeners to think about the dramatic impact this could potentially have, because typically, someone who abuses either prescription or illicit drugs, they're not going to really want to go through the process of getting a Naloxone device, typically, but maybe a concerned family member or friend who's seen them overdose multiple times have to go to the ER now this offers that family member or friend the ability to provide this medication to their their loved one or friend without, you know, having to go through the hassle, if you will, of having that person go to prescriber to get the prescription, to have this medication. Speaker 2 08:31 Yeah, and, you know, just to play and devil's advocate to a lot of pharmacies. Or pharmacy owners are also concerned, because if their pharmacies are located in an area where there is high numbers of heroin abusers, then the word's gonna get on the street that this pharmacy provides that, and they're gonna flock the pharmacy. So if these laws are still in its infancy, we haven't really seen the total impact of how you know, the practice has been with this new laws, the training and everything, but some pharmacy owners are definitely concerned how they're going to or how, what kind of a reaction and community it's going to be and what, how it's going to impact their pharmacies and their workflow. Speaker 1 09:15 Dr. Patel, that's a great point, and in light of that, I believe, for example, the see the CE or the training that's required to be able to do this program. We'll get to some of that. Some of the things that are discussed are opioid overdose prevention itself, reducing the risk of prescription overdose, how you would educate a patient on it safe, use of opioids for chronic pain, use of screening tools. So again, another thing sort of the pharmacist, who is we're going to be able to detect whether or not their patients may be abusing or be dependent, how to manage difficult patients, for example, how to manage diversion education on the kit itself, protocols as well as how to activate the emergency response system. Some of those liabilities there, all of those are well delineated. Within, within this protocol, and the CE that's there to kind of help with that. So again, it is standardized, and it may be allay some of those, those fears potentially that a pharmacist or pharmacy owner may have Sure. Speaker 2 10:11 And then so you mentioned that the training program is rolled out by the Department of Human Services. But is there anybody, particularly in Illinois, or if our listener wants to get a training, where would they go and enroll themselves to get the training? Speaker 1 10:26 Well, the first and main one out there is going to be through the Illinois Pharmacists Association (IPhA) and through their website. Kelly Gable, Chris Herndon, Jessica Kerr, and Garth Reynolds, a few of the individuals who have been involved and who also did the CEs there last year, have made this webinar available for CE on the website. And if you complete this program, there's a nominal fee attached to it, but if you complete the program again, you can have that certification to be allowed to do this in your pharmacy. Dr. Sean Kane 10:55 So Dr. Sherman, once you complete the CE, help me understand kind of the A to Z, the nuts and bolts of if you're a pharmacist, you've done the CE what does it look like to actually dispense one of these kits or injectable agents? Speaker 1 11:08 Again, the first thing to do is going to be identify the individual who would benefit from the receipt of the medications. Again, you have someone who is potentially is dependent, so based upon whether it's prescription fills, whether it's based upon, you know, signs and symptoms, if it's in more of a clinical setting, or, again, knowledge of or reports from family members, for example, if you said, All right, based upon what I see or have heard, then this individual is at risk. Then you determine, Okay, we need to move forward with the kit. First thing to do is you talk about signs and symptoms of overdose. So again, looking at breathing, looking at the the pupil dilation, looking at, you know, this, the skin itself, looking for some of the response. So if you were to walk into a room and somebody's not arousable, even with a little whether it's a certain rubber rubbing of the chest or be loud or being gently shaking again, shaking the shoulder, saying something like, if you don't move, I'm going to call the police something like that, to get their attention and make sure that this individual is not just a sleeper past that, but once you determine that, you start the rescue breathing, and then, depending upon the number of individuals, they are also the activation of the emergency response system. And so those are important steps too, because this individual, who you know needs to be make sure, again, at first, do no harm. So also need to be while we're still giving the Naloxone kit, we want to make sure we're using it for the right type of emergency. Dr. Sean Kane 12:27 So just to be clear, what you're saying is that you're providing counseling to the person receiving the Naloxone what to do in the event of an emergency. You're not doing it per se. You're educating the person picking up the prescription product, what to do in the event that it needs to be used, correct. And this is Speaker 1 12:45 standard, again, per the state of Illinois as well as this is when we do it within our VA setting. There's been a number of kits that we have dispensed, and again, always pursuant to having this counseling for the individual, and ideally sitting down right with them, walking through it, and then kind of going next into the show and tell section. So again, once we know that we've been able to address it with an emergency response system, help is on the way, what do you do with that kit that you do have there? And there's a few different ones, we're really phasing out those intranasal atomizer kits as well as those intramuscular kits as well those that I know, Dr. Patel, you and I discussed last year those were really being phased out for these pre assembled devices, Speaker 2 13:24 those are pretty interesting to play around with, but I wasn't really sure if in a situation as emergent as it is, that the administer off the Naloxone would be able to properly use it for for the patient or the victim. So we've come up with some sophisticated kits as well, and it will be with the route of intramuscular injection, right? Speaker 1 13:47 So we have the intramuscular autoinjector (Evzio), and this one comes in a nice little box with two devices per box. Each one is it's all housed within the same device. A little almost looks like a deck of cards. And there's also within the box again, two of these devices as well as it comes with the trainer. And the trainer there is black and white with a little red cap on. You pull it off. It talks you through how to give it and you simply pull off the guard, place it against the side of the outer thigh. Hold it down for a number of seconds, and then you actually hear a clicking sound. It'll tell you the injection is completed. And then so we have the practice device as well as two of the kits. And the important thing is you go ahead and give the dose by, again, after removing the guard, placing it against the thigh; you can go through clothing if needed, but if you really want to make it less difficult, you can remove the clothing on the side of the leg if at all possible. But again, an emergency don't need to, but you get once you give it. The important thing is that you're also doing monitoring. Because a number of opioids, for example, we think of methadone as one that has very, very, very long half life up to a number of days. And if that's the case, the Naloxone will get out of the system well before the methadone does. And then that individual, you may think, Okay, well, I've done my community. So. Service Time to move on from here, the individual may end up right back in the same spot they're in, so that's where continuing monitoring and then also go right back into rescue breathing Dr. Sean Kane 15:08 until help arrives. What kind of dose are we giving with the Evzio kit? Speaker 1 15:12 So with the Evzio kit, we're giving a 0.4 milligram dose, and that's the same dose as was in the previous one when they were preassembled. Dr. Sean Kane 15:21 So it's interesting that you said that you actually have two items per kit. Do you really need that second one or kind of, what is the thought process with that Speaker 1 15:29 couple things again? One, it's, you know, if it need did arise again, so you're not out of luck. But also, the idea that you may need a second device for that, for that same incident, owing to the half life of a number of these medications, and we think of methadone as an example, especially if you don't know licit or illicit, you don't know what particulate it is, is there something else laced in with the heroin that could have a totally different half life of it? So to be sure, you watch and you monitor that individual again, looking for their breathing, looking at their pupils, looking for those same signs and symptoms of an acute overdose. And then if you need to, generally, within two to five minutes, you may be able to, may repeat a dose as needed, Speaker 2 16:10 and hopefully by the second dose, a Help is on the way to further manage the patient symptoms. Dr. Sean Kane 16:15 And just to give context, sometimes in patients, especially overdose patients, if we have a significant amount of opioid on board, we may actually give the patient in the hospital setting Naloxone continuous infusion, where, because the naloxone is only gonna last, let's say, about an hour, we may actually give the patient a continuous infusion for, let's say, a day until whatever they took is out of their system, correct. Speaker 1 16:40 And then the newest device, recently, one that came out, is a new intranasal device. And this one, since it actually goes by a brand that may be familiar, Narcan. So Narcan was the original brand for the Naloxone itself; Dr. Kane used it in hospitals, I believe, and they've now rebranded this as an intranasal kit, which comes in its own self-enclosed device. And this one, I believe it's a actually a four milligram device, instead of the point four milligrams, due to some concern about bioavailability between intranasal and intramuscular. So using that same brand name of the original Naloxone injection came out through the small device. And this one is much different, very tiny plastic device about maybe two inches by an inch and a half, and it's shaped like the letter T. And so what you just simply do with it is peel back the packaging on it. And again, just to compare, this is compared to the previous intranasal devices, which have been ones coming in these kits where you take a vial and you add an atomizer to it and essentially draw it out and spray it into the nostrils. And concern with that was the number of steps it would take to put it together, and given a crisis situation, not being able to do it appropriately, accidentally spraying it everywhere else, but the nasal mucosa, for example. So with this one, you simply take out the packaging, peel the device out, hold it with your thumb on the bottom of your plunger and two fingers on the nozzle, simply place it within the within the nostril, until your fingers touch the bottom of the patient's nose, and just press the plunger firmly. And that's it Dr. Sean Kane 18:09 seems fairly straightforward. Is one preferred over the other, or does it Speaker 1 18:14 not matter? So there are some concerns, and this has actually been one that's been a little bit of a point of discussion. And so for for the most part, all the devices should be considered available because there is a cost difference between them. So this will be newer, that the cost may be a little bit more, but every one of them has its own pros and cons. So for example, there's a number of settings for some individuals that I've been made aware of who are unable to carry needles around. And so if that's the case, if your job will replace prevents you from having needles around, that's where a nasal kit would be appropriate. Dr. Sean Kane 18:48 Certainly, if we're thinking about, let's say a heroin patient population, things like Hep C and HIV are concerns. And if you're a friend or a family member of a patient like that, you would certainly be worried about a needle stick. So I can see, from you know, a third party point of view, having a needle this system might seem like an advantageous thing if you're working with a high risk group that could potentially transmit, you know, an infectious disease to you correct. Speaker 1 19:12 Now to be clear, the Evzio kit: the way the needle is within there it is essentially encased in the device until it's clicked so there is no active needle that would stick out. But yes, if you are very, very, very concerned about even the mere fact that you would inject it at that moment, if you're say, what if the device malfunction? If that's the concern, yes, the way to completely avoid any kind of blood would be to use this kid. Now the one, the one interesting point of it would be that when they originally did the studies looking at, they looked at bioavailability studies comparing this to intramuscular injection. So what they found is that this four milligram dose was well above the bioavailability of what they needed. So they thought that would be good enough, not too much, so that you were not concerned about, you know, maybe. Causing really, really, really bad withdrawal. But again, it's enough to quantitatively to still have the same effect on reversing some of those symptoms. What they did find, though, is that when they did it, they were either using mannequins or healthy individuals who were asked to lie very still, stop, hold their breath as much as they could. And so it's kind of one of those idealized environments, there's some concern that an individual was not laying exactly still, was moving around a little bit, if there was nasal congestion, if there was maybe some damage to the nasal mucosa. Or a big, big concern is with comorbid drugs, something like cocaine, for example, that would alter the permeability of the vasculature within the nose. Dr. Sean Kane 20:40 So what you're saying is that if you want reliable bioavailability, the evzio kit is going to be more reliable, but the Narcan intranasal spray, maybe, potentially, if a patient was concerned about this needle, even though it's self contained in the device, that maybe they might prefer the nasal version instead. Speaker 1 21:00 Yes, in a nutshell. Again, if you're you know, if you as an individual, if the concern is whether or not the individual would hesitate to use it, that's where the nasal spray may be preferred. But again, if you wanted to be absolutely sure and say that the standard dose is a dose is a dose, I think then, personally, I would consider the Evzio kit to be the way to go. So let's Dr. Sean Kane 21:21 say that you're working in a pharmacy, and a patient or a concerned individual meets the criteria, and you dispense either Evzio or Narcan on the pharmacy side. Are there any other steps that have to happen in terms of, given that this is not a prescription, that you're you're being provided to, like, how do you log that you've provided this and things like that. Speaker 2 21:41 So they have to maintain a log of how many kits have been dispensed, and these are to be kept along with the controlled substance logs. So eventually, when the inventory is being done in terms of controlled substances, and it will be evident to how many dispensed have happened in terms of naloxone dispenses, and also another like you already mentioned, Dr. Schuman. Another duty of a pharmacist would be to encourage the patients to communicate with their doctor. You know, if these are like, this is a fourth or fifth, you know, dispense to the same patient that you know of, then definitely encourage them to talk to the PCP. The idea should be also to equip them with any community based rehab programs, kind of information that we can provide as pharmacists. And obviously, you know, availability of the medication and proper use would also should be documented, right? Speaker 1 22:33 Is, again, this is, this is a piece. This is not the whole stop gap here. This is a piece of the the health care system to help. So in that, you know, there's a time for education about and counseling and behavioral help and ways to prevent future outbreak. But the first thing to do is, you know, this individual to literally save their life in that moment and then make sure that there's a policy in place. So that's not like, Okay, well, you know, we were fortunate here and move on with their lives, but to continue to say, All right, now that this has occurred, let's look at what happened. Let's look at what led up to it, and as a system, as a family, however, however you want to think about it, let's look at mitigating into the future. Speaker 2 23:11 I think I can see this being very smoothly. This interaction being really smoothly. If you're dispensing to a patient who's feeling high doses of opioid prescriptions at your pharmacy, because you're going to talk about the opioids in what it can do, and then you're going to talk about the Naloxone and how it plays along. But I think the circumstances will be different if somebody off the street just came and asked for the Naloxone, and that interaction in itself will be completely different experience altogether. Dr. Sean Kane 23:40 You know, not everyone who listens to the podcast is in Illinois. We said that these are state specific laws, as opposed to a federal law. Dr. Patel, I know that you practice in Wisconsin. Does Wisconsin have a law and does it differ from what we've talked about for Illinois law? Speaker 2 23:55 Actually, I'm very happy to report that Wisconsin passed a standing order of the same sort like the Illinois does on August 26 2016 at our very own pharmacist Society of Wisconsin meeting, Governor Walker came and talk at about one o'clock or two o'clock in the afternoon, and the order was passed at four o'clock in the afternoon. So this shows the real impact of you know, working with your legislators to promote good health among the community. And basically the standing order is the same that you know you can under licensed physician PA or advanced nurse practitioner provider. You can issue a prescription if there is a standing order, there is a blank standing order available too, so they can go ahead and sign it with that advanced practitioner and their requirement currently states that one hour of training should be done with the Department of Health Services of Wisconsin or Pharmacy Society of Wisconsin. So because this was passed just a couple weeks ago, I anticipate that PSW will come up with the same training program that IPhA has developed, Speaker 1 25:04 and the one at this moment, one quick counseling point to add that I, that I neglected to mention before, is the idea about, you know, we talk about, well, as with anything, what are the, what is the risk benefit, and as far as side effects go, again, fairly self explanatory, you are reversing an opioid. So the main things you would look for would be fever, hypertension, tachycardia, agitation on the part of the individual, restlessness, nausea, vomiting, diarrhea, potentially, sneezing, yawning, cramping, that would occur. And again, a lot of it's hard to say how much of it would occur. It's gonna be dependent upon how much of the opioids that person was using, how long they've been using it for? Is this acute? Is this an acute on top of chronic lifestyle? Of it beyond that, it's very, very, very rare to have any sort Dr. Sean Kane 25:49 of other side effects. And I'll tell you from personal experience and seeing patients who receive Naloxone a lot of times, what you'll see is goose bumps, piloerection. Then you'll see yawning. You can see lacrimation of their eyes, and then they start feeling really bad. So they feel like their whole body hurts. They feel nauseous. Oftentimes they'll vomit. So this is not a pleasant feeling that a patient has. And clearly, if they're, you know, abusing an illicit drug like heroin, they're not going to be very happy that they received it, although it was hopefully a life saving treatment for that patient. So in the heat of the moment, they may not realize it that their life was saved, but there's definitely a side effect profile that has to be appreciated, but clearly that dramatically outweighs the benefit of saving someone's life if they stop breathing because they received an opioid overdose. Speaker 1 26:41 And that's, again, where it's, you know, it's not just upon that individuals provide all the counseling on why, you know, why did you give me this? What's going to happen next? And that's where it's the clarity of continuing to engage with healthcare system and behavioral health system through further counsel. Moving forward Speaker 2 26:55 on this, be very interesting to see if a patient who was revived using Naloxone would then be suing the person or suing the pharmacist or healthcare provider who provided the medication. But I suppose that this law also covers the practitioner under the Good Samaritan Law, so that should not be the case. So if there was ever a fear against dispensing Naloxone kits because of such issues, the listeners should be aware that we are covered under the Good Samaritan Law. Speaker 1 27:26 That's That's correct. Dr. Patel, it's actually a really good point. Yes, it was very clear that this is still part of that same coverage that's provided to a responder in any other situation. Dr. Sean Kane 27:35 And you know, from a research perspective, one thing that makes us right for research is that we do have state by state initiatives that either allow this or don't allow this, and it'll be really interesting, given the logs that we now have of who's picking up Evzio or Narcan in terms of do we actually see from an epidemiologic standpoint, do we see fewer opioid related deaths in areas that do have this law, or in areas where, based on the log, we know that they've picked up a lot of Narcan, as you so clearly, like intuitively, you would assume that giving this out to a bunch of people will help reduce opioid related deaths, but there's certainly another camp of people who say, Well, if you give them the safety net, they're more likely to abuse opioids or encourage their use and things like that. We don't know the answer yet, but let's say, five years, hopefully we'll have sufficient data to compare Illinois versus Nebraska, or whatever state you want to pick that either does or doesn't have the law to see how do opioid related deaths change over time, given that we have, you know the availability of these products. It's a Speaker 1 28:43 great point. Dr. Kane's thus far, especially from what I'm aware of, most of the data is just numerically looking at the number of deaths that were prevented as as you serve these kits. And states like Massachusetts or Rhode Island, who have been doing this for a number of years, especially, have been reporting it more and more for a while. But as we continue to go on again, looking at those, those regions or counties where kids are and trying to correlate them with decreases the number of heroin or opioid related deaths. And that certainly is going to be a priority, and something that I think we're even currently working on within within Lake County here, Speaker 2 29:14 yeah, and I think you know, this is something immediately or immediate issue that we're working on to prevent the deaths. But I think our ultimate goal as a healthcare community would be to make sure that these folks find right help. AKA, we have programs within the community, and they're successful in perhaps quitting their abuse abusing agent. Dr. Sean Kane 29:36 So just to kind of wrap a couple things up, one thing that I think is important is that any pharmacist that participates in this Naloxone program has to be trained. Obviously, it is state specific, depending on what state you're in, what the laws are. But generally, there's some kind of a training program to make sure that that pharmacist is competent and knowing about the dosage forms, how to counsel patients, recognize patients at risk, things. Like that. So not every pharmacist will be able, under the law, to provide this medication, Speaker 2 30:06 and like Dr. Schuman mentioned, some of the East Coast states have been doing it for a while, but Illinois has been approved in case of pharmacists dispensing Naloxone kits. So there is a standing order approved since 2015 Wisconsin was another state that just joined this August, and basically that standing order is in collaboration with either a physician, a PA or advanced nurse practitioner, where they sign the orders. And under that standing order, pharmacists will be able to dispense the kits to either patients who hold opioid prescriptions or patients who are supposedly heroin abuser off the street. And I Speaker 1 30:43 wanted to be clear about the availability of these devices and kits we have thus far. Technically, there are four. We're currently phasing out the two of the kit. So there's a kit that must be assembled, and that would be the intramuscular kit and the intranasal kit that come, generally in bags that will be given from the pharmacy and the individual and the moment would put it together and use it as a single device. And then we have the most recently approved devices: Evzio (the intramuscular autoinjector), a single enclosed device with a retractable needle, and Narcan (the intranasal spray device), which is a small plastic device shaped like the letter T that you would spray into the nostrils. Both of those new devices come in groupings of two and include trainer information; there are two devices per box so you can repeat a dose if necessary. Dr. Sean Kane 31:35 So with that, I think that wraps up, pharmacist to the rescue, talking about Naloxone and some of the new initiatives for pharmacists, role with naloxone. If you haven't done so already, give us a five star review on iTunes. Follow us on Twitter at HelixTalk, or visit us on our website at HelixTalk.com where you can see show notes and more information about the content of the episodes. So with that, I'm Dr. Kane, I'm Unknown Speaker 31:57 Dr. Schuman, and I'm Unknown Speaker 31:58 Dr. Patel, and as always, study hard Narrator - Dr. Abel 32:01 if you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 32:13 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.