In the United States, as in most countries, naloxone – though a very safe and easy-to-use medication – requires a doctor’s prescription. Many harm reduction organizations partner with friendly doctors who visit the organization a few hours each week to issue naloxone prescriptions. But doctors are not always available when clients want naloxone, meaning that organizations aren’t always able to legally distribute naloxone to clients who want it. Some U.S. locales have eliminated this barrier by using what is called a “standing order” model.
What is a standing order?
A standing order is a physician's order that can be exercised by other health care workers when predetermined conditions have been met.
Under this model, a doctor with prescriptive authority issues a written order that naloxone can be distributed by designated people, such as trained employees of a harm reduction program, to those who meet the criteria outlined in the document. Some standing orders are written so that distribution is not limited to people at personal risk for overdose. In these cases, a potential bystander, such as a family member, could procure and administer naloxone in case of an emergency. In fact, in many places, ambulance workers who do not have prescriptive authority already administer naloxone under a standing order from their medical supervisors.
This model has contributed to the widespread distribution of naloxone in states like California and Massachusetts, where tens of thousands of vials of naloxone have been distributed to date.
The “DOPE Project” Model
The standing order model used in San Francisco, California authorizes an overdose prevention project, called the “DOPE Project,” to maintain supplies of naloxone and allow the project’s overdose prevention educators to possess and distribute the medicine to potential responders who have completed overdose training. Furthermore, it authorizes trained employees of the DOPE Project to administer naloxone in an emergency. Before they can train others, overdose prevention educators must attend a training conducted by the DOPE Project manager with oversight from the city’s medical director.
The DOPE Project’s standing order starts with information about naloxone’s clinical pharmacology (explaining how it works on the body); contraindications (that naloxone should not be used on people known to be allergic to it); other warnings and precautions; information about adverse reactions; and dosing. Next, it describes the DOPE Project and the training criteria that clients must meet. Finally, it includes an order to dispense naloxone to those who complete the specified training and gives directions for naloxone administration. At the bottom it has space for the physician’s signature and license number, full name, the date of the standing order, and the standing order’s expiration date – typically a year or two after it’s issued. The standing order also includes references to various peer-reviewed articles about naloxone and its distribution to laypeople. The Massachusetts standing order is even more basic.
In San Francisco, naloxone is purchased by the Department of Health under the medical license of the medical director, who is a city Department of Health employee. Each box of naloxone is labeled to indicate that it was distributed with the clinical oversight of the medical director. The DOPE Project manager observes the educators as they distribute naloxone initially and then yearly after that, and reviews the registration and refill forms that the educators submit. Any clinical issues are referred to the medical director.
An approach approved by doctors
Using a standing order to authorize non-medical personnel to issue naloxone is a new practice in the United States, and it has never been challenged in a court of law. However, doctors in Massachusetts and San Francisco feel so strongly that laypeople can safely and successfully use naloxone, that they are willing to put their names to it. "The Department of Public Health asked me to sign a standing order and it seemed such a simple, direct thing to do with little downside,” says Dr. Alexander Walley, who issued the Massachusetts standing order. “I'd heard colleagues talk about the desire of active drug users to have better tools to prevent overdose themselves. I did not feel like a lone wolf, but, rather fortunate to be a part of a brilliant idea."
The Massachusetts program recently documented that communities in the state that had overdose prevention education and naloxone distributions (using the standing order model) had significantly lower rates of overdose death than communities without these programs.