In the United States, as in most countries, naloxone – though a very safe and easy-to-use medication – requires a doctor’s prescription. Some harm reduction organizations partner with friendly doctors who visit the organization a few hours each week to issue naloxone prescriptions (typically the doctor writes the prescription and a harm reduction worker does the training and dispenses the medicine). But doctors are not always available when participants want naloxone, meaning that organizations aren’t always able to legally distribute naloxone to clients who need it. Some U.S. locales have eliminated this barrier by using what is called a “standing order” model. Several states have even gone so far as issuing a statewide standing order for naloxone.
What is a standing order?
A standing order is a physician’s order that can be carried out 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. Under this scenario, someone can receive naloxone without ever meeting the doctor who officially prescribed it. Some standing orders are written so that distribution is not limited to people at personal risk of overdose. In these cases, a potential bystander, such as a family member, could procure naloxone to administer in an emergency.
In practice, the standing order allows harm reduction outreach workers to train drug users and their loved ones on overdose response and then equip them with naloxone without a doctor being present.
More than half of the 50 U.S. states now have naloxone standing order programs. These programs have gone a long way to increasing distribution of naloxone and saving lives from overdose. For example, in North Carolina, prior to using a standing order model, in 2012, outreach workers for the North Carolina Harm Reduction Coalition (NCHRC) distributed 201 vials of naloxone and recorded 30 reversals. In 2015, under a doctor’s standing order, they distributed 15,879 naloxone doses and recorded 1,547 overdose rescues. You can see NCHRC’s standing order document here.
This model works well if a harm reduction organization can find a supportive doctor to issue the standing order. NCHRC talked to more than 100 doctors before finding one willing to issue the order under his license. A few U.S. states have eliminated this hurdle by issuing a statewide standing order.
What is a statewide standing order?
Under this model, the Physician General (the top physician of the state) issues a statewide written order that naloxone can be distributed by designated people, such as pharmacists or other people who meet the criteria outlined in the document.
This model has contributed to the widespread distribution of naloxone in states such as Pennsylvania and Maryland, where tens of thousands of vials of naloxone have been distributed to date.
The Pennsylvania Model
The statewide standing order model used in Pennsylvania allows for pharmacists in the state to dispense naloxone under Physician General Rachel Levine’s standing order. The statewide standing order has increased the availability and accessibility of naloxone by allowing anyone to walk into their local pharmacy and buy the medication.
For a large state like Pennsylvania, a statewide standing order for pharmacists is vital to getting naloxone into the hands of people living in rural and remote parts of the state.
“There are two community-based programs doing large-scale dispensing of naloxone in the whole state of Pennsylvania: Prevention Point Pittsburgh and Prevention Point Philadelphia,” said Alice Bell, Overdose Prevention Project Coordinator of Prevention Point Pittsburgh. “The statewide standing order definitely helps increase access [to other parts of] the state.”
Alice says the statewide standing order allows them to direct people to their local pharmacy to inquire about obtaining naloxone. “While not all pharmacies are participating in the standing order, we are finding that in a lot of towns, there is a pharmacy where people can get naloxone,” Alice said. “We encourage people to talk to their local pharmacists and ask if they are participating. Hopefully, this can increase pharmacist awareness and participation.”
The statewide standing order in Pennsylvania provides information on how to recognize the signs of an opioid overdose. It recommends that people receive an online training on how to use naloxone, but the training is not required to obtain naloxone. Pennsylvania’s statewide standing order also includes directions on how to administer naloxone and what to do during an opioid overdose.
A local website features a map of pharmacies in Pennsylvania that stock naloxone under the statewide standing order, allowing employees of overdose prevention programs to direct laypeople to a participating pharmacy in their area.
Revolutionizing naloxone distribution
Standing orders have revolutionized the way that naloxone is distributed in the United States. As more states have adopted them, programs have flourished. For example, where there were only 33 programs distributing naloxone in 2009, by 2014 there were five times as many. While other countries may not have the exact same legal mechanism, they may be able to find similar creative workarounds to expand access.