2025 Southeastern Residency Conference

Implementing A Practical and Effective Approach to Expand Naloxone Access for Geriatric Veterans at the Salisbury VA Health Care System (SVAHCS)

Authors: Elizabeth Martinez Delgado, Allison E. Strain, Chelsea McDonnell, Camille Robinette, Sarah J. Hopper
Salisbury Veterans Affairs Health Care System – Salisbury, NC

Objective: Compare percentage of naloxone prescriptions initiated by pharmacist and primary care provider (PCP) to older adult high-risk Veterans. 

Self-Assessment Question: Based on the objective of this quality improvement project, which of the following Veterans would be more likely to accept a supply of naloxone spray?
 
Background/Purpose: Veterans aged 65 years and older, due to physiological changes experienced through the aging process, are at an increased likelihood of developing enhanced side effects to opioids and sedatives. Due to these concerns, access to naloxone in older adults prescribed a combination of opioid prescriptions plus sedatives is important to reduce the risk of opioid overdose. The purpose of this quality improvement project is to assess whether pharmacist led prescribing increases naloxone access to older adult Veterans in comparison to naloxone prescribing by a primary care provider at the SVAHCS.  

Methodology: Older adult Veterans with an active opioid prescription plus a sedative (barbiturates, benzodiazepines, medications for opioid use disorder, non-benzodiazepines, and skeletal muscle relaxants) will be included. To further assess risk, the Stratification Tool of Opioid Risk Mitigation (STORM) will also be utilized. Through the Opioid Overdose Education & Naloxone Distribution (OEND) dashboard one hundred Veterans meeting these criteria will be identified. Fifty Veterans will be contacted and offered a naloxone prescription alongside naloxone education. A retrospective chart review will be completed to assess if 50 Veterans with scheduled PCP appointments from December 1st, 2024 to February 28th, 2025 were prescribed naloxone by their PCP.

Results: The baseline characteristics of this project include average age 73 years old ± 5.4,  94.6% (n=88) male sex,  75.3% (n=70) white race, and predominant comorbidities were obstructive sleep apnea 45.2% (n=42) and chronic obstructive pulmonary disease 34.4% (n=32). 94.6% (n=88) of Veterans included had a commitment opioid + sedative hypnotic prescription, 6.5% (n=6) included had concomitant opioid + benzodiazepine prescription, 93.5% (n=87) were chronic opioid users, average morphine equivalent daily dose 35.7 ± 38.2, and on average each Veteran had an average of 1.6 ± 1 additional CNS active medications. The primary objective was met in 88.7% (n=42) of Veterans who were initiated on a naloxone prescription by a pharmacist in comparison to 8.3% (n=4) of Veterans receiving a naloxone prescription after their PCP appointment. The secondary objectives resulted 75.6% (n=34) chronic opioid users, 82.2% (n=37) low STORM risk, 17.8% (n=8) medium STORM risk for the targeted pharmacist initiation component and 93.8% (n=45) chronic opioid users, 79.2% (n=38)  low STROM risk, 20.8% (n=10) medium STORM risk for the standard of care, PCP initiation component.

Conclusions: Targeted pharmacist naloxone prescribing yielded positive results. Results are attributed to personalized conversations tailored to Veteran’s medications which increased the acceptance of naloxone supply, opioid overdose education, and medication burden counseling. Overall, naloxone acceptance was unrelated to chronic opioid use, STORM risk, or specific CNS depressant medication. Additionally, naloxone under-prescribing during standard of care in comparison to targeted pharmacist prescribing is likely multifactorial.

Contact Information: elizabeth.martinezdelgado@va.gov