The naloxone option

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Applied Evidence

The naloxone option

J Fam Pract. 2018 May;67(5):288-290,292

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From The Journal of Family Practice | 2018;67(5):288-290,292.

References

1. National Institute on Drug Abuse. Overdose death rates. Revised September 2017. Available at: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed April 11, 2018.

2. Xu J, Murphy SL, Kochanek KD, et al. Deaths: final data for 2013. Nat Vital Stat Syst. 2016;64:1-119.

3. McCabe SE, West BT, Teter CJ, et al. Trends in medical use, diversion, and nonmedical use of prescription medications among college students from 2003 to 2013: connecting the dots. Addict Behav. 2014;39:1176-1182.

4. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction. 2008;103:979-989.

5. US Department of Health and Human Services. HHS takes strong steps to address opioid-drug related overdose, death and dependence. March 26, 2015. Available at: http://wayback.archive-it.org/3926/20170127185704/https://www.hhs.gov/about/news/2015/03/26/hhs-takes-strong-steps-to-address-opioid-drug-related-overdose-death-and-dependence.html. Accessed April 16, 2018.

6. Robinson A, Wermeling DP. Intranasal naloxone administration for treatment of opioid overdose. Am J Health Syst Pharm. 2014;71:2129-2135.

7. Doyon S, Aks SE, Schaeffer S. Expanding access to naloxone in the United States. J Med Toxicol. 2014;10:431-434.

8. National Institute on Drug Abuse. Which classes of prescription drugs are commonly misused? Available at: https://www.drugabuse.gov/publications/research-reports/misuse-prescription-drugs/which-classes-prescription-drugs-are-commonly-misused. Accessed April 16, 2018.

9. Boom M, Niesters M, Sarton E, et al. Non-analgesic effects of opioids: opioid-induced respiratory depression. Curr Pharm Des. 2012;18:5994-6004.

10. Weaver L, Palombi L, Bastianelli KMS. Naloxone administration for opioid overdose reversal in the prehospital setting: implications for pharmacists. J Pharm Pract. 2018;31:91-98.

11. Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367:146-155.

12. Jordan MR, Morrisonponce D. Naloxone. StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441910/. Accessed September 1, 2017.

13. Wilkerson RG, Kim HK, Windsor TA, et al. The opioid epidemic in the United States. Emerg Med Clin North Am. 2016;34:e1-e23.

14. Jeffery RM, Dickinson L, Ng ND, et al. Naloxone administration for suspected opioid overdose: an expanded scope of practice by a basic life support collegiate-based emergency medical services agency. J Am Coll Health. 2017;65:212-216.

15. Drugs.com. Naloxone. Available at: https://www.drugs.com/pro/naloxone.html. Accessed April 16, 2018.

16. Prabhu A, Abaid B, Naik S, et al. Naloxone for opioid overdoses. Internet and Psychiatry 2017. Available at: https://www.internetandpsychiatry.com/wp/editorials/naloxone-for-opioid-overdoses/. Accessed September 19, 2017.

17. HHS.gov. Surgeon General releases advisory on naloxone, an opioid overdose-reversing drug. Available at: https://www.hhs.gov/about/news/2018/04/05/surgeon-general-releases-advisory-on-naloxone-an-opioid-overdose-reversing-drug.html. Accessed April 16, 2018.

18. US Department of Health and Human Services. Surgeongeneral.gov. Surgeon General’s advisory on naloxone and opioid overdose. Available at: https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html. Accessed April 16, 2018.

19. Behar E, Rowe C, Santos GM, et al. Acceptability of naloxone co-prescription among primary care providers treating patients on long-term opioid therapy for pain. J Gen Intern Med. 2017;32:291-295.

20. Albert S, Brason FW 2nd, Sanford CK, et al. Project Lazarus: community‐based overdose prevention in rural North Carolina. Pain Med. 2011;12:S77-S85.

21. Rowe C, Santos GM, Vittinghoff E, et al. Predictors of participant engagement and naloxone utilization in a community‐based naloxone distribution program. Addiction. 2015;110:1301-1310.

22. Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165:245-252.

23. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.

24. Bird SM, McAuley A, Perry S, et al. Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison. Addiction. 2016;111:883-891.

Expanding the availability of naloxone in the community

The availability of naloxone overdose-reversal kits is growing among hospitals, other types of health care facilities, first responders, medical offices, and the general public. Distributing the kits to opioid users and their families has wide support but remains controversial (more on this in a bit).

Opioids are responsible for 61% of drug-overdose deaths.

Support even includes that from the current US Surgeon General, Jerome Adams, MD, MPH, who noted in a statement on April 5, 2018, the lifesaving success of opioid-overdose reversal naloxone kits by medical personnel, first responders, and other people. As a result, he formally recommended that more Americans keep such kits available in order to be able to quickly diminish opioid toxicities.^17,18 His advice was especially directed toward people at risk for an opioid overdose or anyone associated with opioid drug users.

Prehospital management of overdoses is ideally managed by emergency medical service (EMS) personnel,¹⁰ but even nonmedical people can safely administer naloxone. About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.¹⁰Many states have laws limiting the civil and criminal liability for naloxone administrators. New Mexico was the first state to legally allow naloxone administration by individuals without a prescription.⁷Pharmacists often participate in efforts to counter opioid drug overdose deaths by offering naloxone administration kits, along with training about techniques of use, to people filling opioid prescriptions and to household members and/or other individuals in the social support network of an opioid user.⁶ Some physicians co-prescribe naloxone to patients along with opioid therapies during long-term pain management. Such dual prescribing is encouraged by many clinics.¹⁹This method has decreased opioid overdose deaths in North Carolina,²⁰ in its army base at Fort Bragg,¹⁹ and in California.²¹

The issue of “risk compensation”

About 10,000 overdose cases were documented to have been reversed by nonmedical providers between 1996 and 2010.

To those who say that having naloxone available to users of opioids or those in their social network promotes even riskier behavior resulting in increased overdoses, research points to just the opposite. A nonrandomized study that examined co-prescribing naloxone to patients on chronic opioid therapy for non-cancer-related pain, documented fewer opioid-related ED visits following use by prescribers and patients at community health centers.²²Other research has demonstrated a reduced number of community-level opioid overdose deaths once opioid overdose education and community naloxone distribution were implemented.^23,24

After the overdose: Getting patients into treatment

After reversing initial toxicities, a protracted period of assessment is required to assure patient safety. Beyond prolonged observation after an overdose, it is critical to recommend and provide long-term substance abuse therapies. Simply reversing the overdose is not medically sufficient, even if postoverdose patients refuse such treatment referrals. The fact that many of these people subsequently die is evidence of the importance of adhering to a formal, long-term chemical dependence intervention program.

Persistent diligence is usually needed to convince a patient who has recovered from an acute drug overdose event to accept a treatment referral. Some EDs institute special teams to facilitate such referrals, using a multidisciplinary approach, including substance abuse counselors and social workers. Referral agencies are also sometimes included to aid patient acceptance and retention in drug abuse treatment interventions. (See "Resources" below for more information.)

SIDEBAR
Resources

The Centers for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain. Available at: https://www.cdc.gov/drugoverdose/prescribing/guideline.html.
National Institute on Drug Abuse. Available at: https://www.drugabuse.gov.
Substance Abuse and Mental Health Services Administration. Available at: https://www.samhsa.gov/find-help/national-helpline.
Your state’s prescription drug monitoring program. Available at: https://www.cdc.gov/drugoverdose/pdmp/states.html.

CORRESPONDENCE
Steven Lippmann, MD, 401 East Chestnut Street, Suite 610, Louisville, KY 40202; Steven.lippmann@louisville.edu.

References

2. Xu J, Murphy SL, Kochanek KD, et al. Deaths: final data for 2013. Nat Vital Stat Syst. 2016;64:1-119.

6. Robinson A, Wermeling DP. Intranasal naloxone administration for treatment of opioid overdose. Am J Health Syst Pharm. 2014;71:2129-2135.

7. Doyon S, Aks SE, Schaeffer S. Expanding access to naloxone in the United States. J Med Toxicol. 2014;10:431-434.

9. Boom M, Niesters M, Sarton E, et al. Non-analgesic effects of opioids: opioid-induced respiratory depression. Curr Pharm Des. 2012;18:5994-6004.

10. Weaver L, Palombi L, Bastianelli KMS. Naloxone administration for opioid overdose reversal in the prehospital setting: implications for pharmacists. J Pharm Pract. 2018;31:91-98.

11. Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367:146-155.

12. Jordan MR, Morrisonponce D. Naloxone. StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK441910/. Accessed September 1, 2017.

13. Wilkerson RG, Kim HK, Windsor TA, et al. The opioid epidemic in the United States. Emerg Med Clin North Am. 2016;34:e1-e23.

15. Drugs.com. Naloxone. Available at: https://www.drugs.com/pro/naloxone.html. Accessed April 16, 2018.

20. Albert S, Brason FW 2nd, Sanford CK, et al. Project Lazarus: community‐based overdose prevention in rural North Carolina. Pain Med. 2011;12:S77-S85.

21. Rowe C, Santos GM, Vittinghoff E, et al. Predictors of participant engagement and naloxone utilization in a community‐based naloxone distribution program. Addiction. 2015;110:1301-1310.

The naloxone option

References

Expanding the availability of naloxone in the community

The issue of “risk compensation”

After the overdose: Getting patients into treatment

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