Training Pharmacy Students to Manage Opioid Overdoses and Administer Naloxone

by Cole Sisson, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course Am J Pharm Educ 2020; 84 (2): Article 7179.

Opioid overdoses caused almost 47,000 deaths in the US in 2018 and, according to the CDC, the number of deaths has been growing since 1999.¹ With the continuing increases in deaths due to prescribed and synthetic opioids, it is more important than ever that Americans be knowledgeable about and have access to overdose reversal agents like naloxone, which is a life-saving medication when administered correctly to those experiencing an overdose. Naloxone is commonly carried by emergency medical personnel and first responders, but the average person can be trained on its use.  Wide-spread availability of naloxone can expand the likelihood that someone will have access to this medication when needed. Naloxone dispensing and training is especially important in community settings like pharmacies, however many patients (and even some pharmacists) are reluctant to use naloxone due to a lack of confidence using an injectable medication and stigma related to opioid use. Integrating training about opioid overdoses and naloxone prescribing in pharmacy school curriculums can increase knowledge among new pharmacists entering the profession who can advocate for increased use and availability of these rescue medications.

At the Notre Dame of Maryland School of Pharmacy, Kwon and faculty colleagues designed, implemented, and evaluated an opioid overdose education and naloxone distribution (OEND) program.² They designed a program based on the 5 E’s learning method: Engage, Explore, Explain, Elaborate, and Evaluate.  To measure knowledge and attitudinal change, the investigators used the Opioid Overdose Knowledge Scale (OOKS) and Attitude Scale (OOAS) before and after the OEND program. The faculty engaged a class of P3 pharmacy students in a patient care laboratory session consisting of four parts: an interactive introductory presentation, a hands-on session with various placebo forms of naloxone, a large group review of the information learned in the first two parts, and then a patient counseling and overdose care scenario to test the newly learned skills. The students received prompt feedback after completing the scenarios. Afterward, the students took the post-test OOKS and OOAS evaluations.

Fifty-six students completed the OEND program. When compared to the baseline, the mean OOKS score increased significantly (p<0.001) in each knowledge domain including risk factors for overdose, signs of overdose, actions to care for an overdose victim, and general knowledge about naloxone. Similarly, the mean score in the OOAS evaluation increased significantly (p<0.001) from pre- to post-test, and the largest mean increases in the categories of self-perceived confidence in counseling and dispensing naloxone and counseling on how to rouse and stimulate someone experiencing overdose. As a longitudinal measure of knowledge retention, the pharmacy faculty also included naloxone counseling and overdose care in the final examination for the students that semester. The students were required to counsel a standardized patient on a randomly selected naloxone dosage form, and, in another station, care for a standardized patient who was experiencing an apparent overdose. The mean total score was very high on both of these stations and nearly all students achieved at or above the passing score. While this was not a direct re-administration of the standardized Opioid Overdose Knowledge Scale, it served as a good proxy for retained knowledge by the students.

This study evaluated the effectiveness of a well-designed instructional program and used standardized questionnaires (the OOKS and OOAS) to assess learning. The immediate results following the completion of the program showed significant increases in pharmacy student knowledge and attitudes related to managing an opioid overdose and dispensing naloxone.  While retention of this material was very strong, students were informed that these topics would be tested during the final examination, so it is possible that students did not retain this information so much as relearned it for the exam. This program was implemented with one student cohort at one pharmacy school, so additional studies will be needed to determine the generalizability of these findings to other colleges/schools of pharmacy. 

Similar OEND programs have been implemented and evaluated but none of the reports are as robust as the study by Kwon. Monteiro et al. evaluated an interprofessional workshop focused on increasing knowledge, skills, and attitudes of students towards opioid misuse.  The interprofessional teams included health professional students from medicine, nursing, pharmacy, physical therapy, and social work. While this study only assessed pre- and post- OOKS scores among the medical students, the results demonstrated significant improvements in knowledge.³ In another study, Schartel et al. evaluated the success of a program for P1 pharmacy students in a lab course.  However, they only taught students about and evaluated the use of one naloxone dosage form and, while knowledge improved significantly, they did not assess changes in student attitudes.⁴ 

Pharmacists are one of the most accessible health professionals and many patients ask a pharmacist about a health issue before seeing care from a physician. Implementing training programs in pharmacy curricula can help bridge the gaps in access and increase community awareness about managing opioid overdoses.  Training pharmacists to dispense and teach patients how to use naloxone products can help slow the escalating number of deaths in the US due to the opioid crisis. Interactive and well-designed programs like the one implemented by Kwon and colleagues are an effective way to increase both knowledge and attitudes towards opioid overdoses.

References

1. “Understanding the Epidemic” [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Dec6]. https://www.cdc.gov/drugoverdose/epidemic/index.html
2. Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course. Am J Pharm Educ 2020; 84 (2): Article 7179.
3. Monteiro K, Dumenco L, Collins S, et al. An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills. J Am Pharm Assoc 2017; 57 (2): S113–S117.
4. Schartel A, Lardieri A, Mattingly A, Feemster AA. Implementation and assessment of a naloxone-training program for first-year student pharmacists. Curr Pharm Teach Learn. 2018; 10 (6): 717-722.