Help save lives: Co-prescribe naloxone to patients at risk of overdose

Naloxone saves lives

The nation’s opioid epidemic claimed more than 33,000 lives in 2015, but that figure would have been even higher if it wasn’t for the life-saving opioid overdose antidote naloxone. For more than 40 years, naloxone has been used to reverse the effects of opioid overdose.

Timely administration of naloxone has saved thousands of lives:

• From 1996 through June 2014, organizations that provide community-based overdose prevention services, including provision of naloxone to laypersons, recorded more than 26,000 opioid overdose reversals in the United States. ¹
• In the first 8-weeks of 2017, the number of naloxone prescriptions written by physicians increased 340 percent compared to the same eight-week period in 2016.  The number of physicians prescribing naloxone has also increased 475 percent over the same time period. ²
• When states enact laws to increase access to naloxone, there is “a 9 to 11 percent reduction in opioid-related deaths.” ³
• More than 1,200 law enforcement programs in the United States now supply naloxone to their personnel– resulting in thousands of lives saved. ⁴

Co-Rx naloxone when clinically appropriate

The AMA Opioid Task Force encourages physicians to consider co-prescribing naloxone when it is clinically appropriate to do so. This is a decision to be made primarily between the patient and physician.⁵

Factors that may be helpful in determining whether to co-prescribe naloxone to a patient, or to a family member or close friend of the patient, include:

• Does the patient history or prescription drug monitoring program (PDMP) show that my patient is on a high opioid dose?
• Is my patient also on a concomitant benzodiazepine prescription?
• Does my patient have a history of substance use disorder?
• Does my patient have an underlying mental health condition that might make him or her more susceptible to overdose?
• Does my patient have a medical condition, such as a respiratory disease, sleep apnea or other co-
  morbidities, which might make him or her susceptible to opioid toxicity, respiratory
  distress or overdose?
• Might my patient be in a position to aid someone who is at risk of opioid overdose?

Co-prescribing naloxone is supported by a broad range of stakeholders including the World Health Organization ⁶ , U.S. health agencies (CDC, SAMHSA) ⁷ , state departments of health ⁸ , and many
patient, consumer and other advocacy groups

Additional considerations when co-prescribing naloxone

Determining whether to co-prescribe naloxone raises many issues, including initiating a discussion about the risk of overdose; the potential stigma a patient may experience; engaging the patient in broader discussions about treatment for a substance use disorder, if applicable; and how to ensure the patient (or close friend/family member) has the appropriate training in case of an overdose. Though co-prescribing naloxone is not a guarantee for an overdose reversal, it does provide a tangible option for care that otherwise may not be available in a timely manner.

In addition:

• Co-prescribing naloxone has been found to reduce emergency department visits, and may help patients become more aware of the potential hazards of opioid misuse. ¹⁰
• Patients often find the offer of a naloxone prescription acceptable. ¹¹
• Primary care providers have found co-prescribing naloxone to be acceptable. ¹²
• Co-prescribing naloxone does not increase liability risk. ¹³

Practical resources for more information

• Prescribing Naloxone to Patients for Overdose Reversal – http://pcssmat.org/wp-content/uploads/2016/08/Prescribing-Nalxone-to-Patients-for-Overdose-Reversal.pdf (Providers’ Clinical Support System for Medication Assisted Treatment)
• Putting Naloxone Into Action! – http://pcss-o.org/event/putting-naloxone-into-action/ (Providers’ Clinical Support System for Opioid Therapies)
• Naloxone Distribution from the ED for patients at-risk for Opioid Overdose – https://www.acep.org/uploadedFiles/ACEP/memberCenter/SectionsofMembership/trauma/ACEP_ONDCP%20Naloxone%20Distribution%20Webinar.pdf (American College of Emergency Physicians)
• When Seconds Count: “Opioid Overdose Resuscitation” card – https://www.asahq.org/WhenSecondsCount/resources.aspx (American Society of Anesthesiologists)
• Public Policy Statement on the Use of Naloxone for the Prevention of Drug Overdose Deaths – http://www.asam.org/docs/default-source/public-policy-statements/use-of-naloxone-for-the-prevention-of-opioid-overdose-deaths-final.pdf?sfvrsn=4 (American Society of Addiction Medicine)
• Overdose prevention tools and best practices – http://harmreduction.org/issues/overdose-prevention/tools-best-practices/ (Harm Reduction Coalition)
• Naloxone product comparison chart for brand and generic injectable and intranasal formulations – http://prescribetoprevent.org/wp2015/wp-content/uploads/Naloxone-product-chart.16_01_21.pdf (Prescribe to Prevent)

Task Force organizations

American Academy of Addiction Psychiatry
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Orthopaedic Surgeons
American Academy of Pain Medicine
American Academy of Pediatrics
American Academy of Physical Medicine and Rehabilitation
American Association of Neurological Surgeons and
Congress of Neurological Surgeons
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Physicians
American College of Obstetricians and Gynecologists
American Dental AssociationAmerican Medical Association
American Osteopathic Association
American Psychiatric Association
American Society of Addiction Medicine
American Society of Anesthesiologists
Arkansas Medical Society
California Medical Association
Massachusetts Medical Society
Medical Society of the State of New York
New Mexico Medical Society
Ohio State Medical Association
Oregon Medical Association
Utah Medical Association

Sources

1. Wheeler, Jones et al, “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014” CDC Morbidity and Mortality Weekly Report, 19 June 2015.
2. Symphony Health Solutions—2016/17 Practitioner Level Data
3. Rees, Daniel I., et al. “With a little help from my friends: The effects of naloxone access and Good Samaritan laws on opioid-related deaths,” National Bureau of Economic Research. February
   2017 February 2017. http://www.nber.org/papers/w23171
4. North Carolina Harm Reduction Coalition. U.S. Law Enforcement Who Carry Naloxone. Available at http://www.nchrc.org/law-enforcement/us-law- enforcement-who- carry-naloxone/
5. Many states also have enacted “standing order” legislation that allows a patient to obtain naloxone without a patient-specific prescription.
6. World Health Organization, “Community Management of Opioid Overdose”, 2014.
7. CDC, Guideline for Prescribing Opioids for Chronic Pain, Recommendation 8; SAMHSA, Opioid Overdose Prevention Toolkit, p.12-13.
8. E.g.: Vermont Department of Health, Maryland Department of Health and Mental Hygiene, Rhode Island Department of Health.
9. E.g.: Harm Reduction Coalition, Caregiver Action Network, Young People in Recovery, Facing Addiction.
10. Coffin, Behar et al, “Nonrandomized intervention of Naloxone Coprescription for Primary Care Patients Receiving Long Term Opioid Therapy for Pain,” Annals of Internal Medicine, 20 August 2016. For patients who received a prescription for naloxone, there was a reduction in emergency
    department visits by 47 percent after 6 months and 63 percent after one year.
11. Behar, Rowe et al, “Primary Care Patient Experience with Naloxone Prescription”, Annals of Family Medicine, September 2016.
12. Behar, Rowe et al, “Acceptability of Naloxone Co-Prescription Among Primary Care Providers Treating Patients on Long-Term Opioid Therapy for Pain”, Journal of General Internal Medicine, November 2016.
13. Davis, Burris et al, “Co-prescribing Naloxone Does Not Increase Liability Risk”, Journal of Substance Abuse, October 2016.