Opioid Overdose Information for Pharmacists

Pharmacist Protocol for Prescribing and Dispensing Naloxone HCl Outside the Licensed Pharmacy Premise

Steps

1. Download the Protocol
2. Download and complete the Protocol Request for Approval
3. Email (preferred) or Mail the Protocol Request for Approval along with the Protocol to DCP.DrugControl@ct.gov or the mailing address on the form. (This should be completed 30 days prior to the event)
4. Wait for the Approval Letter from the Drug Control Division (Sent via email)
5. Report the total number of naloxone units prescribed and dispensed to DCP.DrugControl@ct.gov.

Helpful forms

• Sample Atomizer Inventory Form
• Sample Auto-injector form
• Sample Nasal Spray form
• Sample Vial Form
   
  Certification Program
  University of Connecticut School of Pharmacy (ACPE #0009-9999-15-073-H03-P)
  Pharmacist Letter (ACPE # 0422-0000-15-652-H01-P and 0422-0000-16-242-H01-P)
  Walgreens Connecticut Naloxone Training
  Handouts and Forms
  Notice: Pharmacists May Continue to Prescribe Naloxone (9/27/2023)
  Naloxone Handout
  Treatment Providers Handout (By Region)
  Counseling Documentation Form (For Pharmacists)
  Frequently Asked Questions
  Naloxone Flyer
  Naloxone Pharmacy Flyer
  Suggested Intranasal Naloxone Kit Components
  2 x 2 mg/2 mL prefilled naloxone cartridges
  2 plastic syringes
  2 mucosal atomization devices
  A rescue breathing mask
  Step-by-Step instructions for responding to an opioid overdose (See Naloxone Handout above)
  Directions for naloxone administration (See Naloxone Handout above)
  Sample Prescription for Intranasal Kit (use Adobe Acrobat for best results)
  VA Intranasal Counseling Video
  Suggested Intramuscular Naloxone Kit Components
  2 naloxone 0.5 mg/mL vials
  2 intramuscular plastic syringes
  A rescue breathing mask 
  Step-by-Step instructions for responding to an opioid overdose (See Naloxone Handout above)
  Directions for naloxone administration (See Naloxone Handout above)
  Sample Prescription for Intramuscular Kit (use Adobe Acrobat for best results)
  VA Intramuscular Counseling Video
  Suggested Auto Injector Naloxone Kit Components
  Commercially available as a twin pack with audio instructions in English from the device
  NOTE:  If the naloxone auto-injector is prescribed a copy of the Naloxone Handout may still be provided
  A rescue breathing mask
  Sample Prescription for Auto Injector Kit (use Adobe Acrobat for best results)
  VA Auto Injector Counseling Video
  Resources
  Department of Mental Health and Addiction Services
  Prescribe to Prevent Website
  Connecticut Prescription Monitoring and Reporting System
  Governor's Prevention Partnership
  Connecticut Prevention Network