Updated 'Tool Kit' to Prevent Opioid Overdose

Pauline Anderson

September 08, 2014

LAS VEGAS, Nevada — As another weapon in the war against drug abuse, doctors are being encouraged to prescribe the opioid antagonist naloxone when they first treat a patient with methadone or oxycodone.

This recommendation was included in the new overdose "tool kit" released by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency of the US Department of Health and Human Services.

The new tool and other initiatives to counter increasing drug overdoses were discussed during the PAINWeek meeting here.

Opioid overdose is a major and mounting public health problem. It accounts for almost 17,000 deaths every year in the United States.

Naloxone binds to opioid receptors and is the antidote to acute opioid toxicity. Earlier this year, the US Food and Drug Administration (FDA) approved a new naloxone hydrochloride injection system (Evzio, Kaléo) that rapidly delivers a single dose of naloxone intramuscularly or subcutaneously via a convenient hand-held autoinjector. It's the first naloxone treatment specifically designed to be given by family members or caregivers.

While the already available naloxone kits that include a syringe and naloxone ampules or vials require the user to be trained on how to administer the drug to a victim, no special training is required to use Evzio. Similar to automated defibrillators, once this new device is turned on, it provides the user with verbal instructions on how to deliver the medication.

According to SAMHSA's tool kit, candidates for naloxone include those who are:

  • taking high doses of opioids for long-term management of chronic pain;

  • receiving rotating opioid medication regimens (and so are at risk for incomplete cross-tolerance);

  • discharged from emergency medical care following opioid intoxication or poisoning;

  • at high risk for overdose because of a legitimate medical need for analgesia, coupled with a suspected or confirmed history of substance abuse, dependence, or nonmedical use of prescription or illicit opioids; or

  • taking certain opioid preparations, such as extended-release/long-acting preparations, that may increase risk for opioid overdose.

Some states have implemented naloxone laws that make it easier for medical professionals to prescribe and dispense naloxone, Lisa McElhaney, vice president, National Association of Drug Investigators, Lutherville, Maryland, told PAINWeek delegates. To date, 25 states have passed such laws, she said.

Physicians may be hesitant to prescribe naloxone, believing that by doing so they could be admitting to prescribing opioids to people who shouldn't get them. However, healthcare professionals should not be concerned about legal risks, said McElhaney.

"Prescribing naloxone to manage opioid overdose is consistent with the drug's FDA-approved indication, resulting in no increased liability so long as the prescriber adheres to general rules of professional conduct."

Saves Lives

Lynn Webster, MD, a pain expert and vice president, scientific affairs, PRA Health Sciences, Salt Lake City, Utah, said he is pleased to see such proactive moves in the fight against drug abuse.

"Basically, this is taking off the table the legal liability of prescribing naloxone because there's too much of an upside, too much potential benefit of saving someone's life," he told Medscape Medical News.

Dr. Webster said the ready availability of naloxone could potentially prevent thousands of overdose deaths. He has heard too many stories of a family member who couldn't shake awake a loved one who was clearly having trouble breathing. "If they had something like naloxone, those individuals could have been saved."

According to SAMHSA, most private health insurance plans, Medicare, and Medicaid cover the cost of naloxone for the treatment of opioid overdose, although policies vary by state. The cost of take-home naloxone should not be a prohibitive factor, it said.

New York State is the first state to take proactive steps toward insurance reforms along with new treatment protocols, insurance protections, and educational campaigns to address the growing drug epidemic, noted McElhaney.

Naloxone has no psychoactive properties, has no potential for abuse, and is relatively inexpensive at $6 per kit, according to McElhaney. However, she noted, it is not effective with benzodiazepines, barbiturates, or stimulants.

As well as prescribing naloxone with the initial opioid, physicians should properly assess patients and use state-run prescription drug monitoring programs. Prescribers can check the relevant databases to determine whether patients are filling the given prescription and whether they're getting prescriptions for the same or similar drugs from multiple physicians.

In addition, providers should select the appropriate medicine and execute proper prescription orders to prevent manipulation by patients or others, said McElhaney. For example, federal law requires that prescription orders for controlled substances be signed and dated on the day they're issued.

Heroin Epidemic

In her presentation, McElhaney discussed the history of heroin use up to what she called the current "epidemic."

"We have a very, very significant problem," she said, adding that some of the upsurge has been driven by a cut in the supply of prescription opioid drugs.

Data from the National Institute on Drug Abuse indicate that heroin is the most or one of the most important drug abuse concerns across the United States, said McElhaney.

The rise in heroin use is leading to more drug overdose deaths. In February of this year, SAMHSA issued an alert about a marked upswing in deaths linked to the use of heroin contaminated with the opioid fentanyl. Fentanyl is reported to be about 100 times more potent than morphine, the active ingredient of heroin.

But there are also sweeping changes being implemented by governments and others. In the last 5 years, said McElhaney, arrests of dealers and suppliers of opioids when there has been a death have increased substantially. The message is, if you sell people drugs and they die, you may be charged with reckless homicide, she noted.

Also in the increasing effort to reduce drug overdose deaths, some states have passed Good Samaritan laws. To date, 21 states have this legislation, which encourages those witnessing overdoses to call emergency medical services and exempts them from arrest and prosecution for minor drug and alcohol law violations.

Some states, including California, Washington, and New York, have passed both Good Samaritan laws and naloxone laws.

Yet another step toward solving the drug overdose problem is providing physicians with free access to federally funded continuing medical education courses. Visit www.opioidprescribing.com — a site sponsored by Boston University School of Medicine Continuing Medical Education — for more information.

Another useful resource is the Prescriber's Clinical Support System (www.pcss-o.org or www.pcssmat.org). Sponsored by the American Academy of Addiction Psychiatry in collaboration with other specialty societies and with support from SAMHSA, this system offers multiple resources related to opioid prescribing and the diagnosis and management of opioid use disorders.

To access the overdose tool kit, log onto http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA14-4742?WT.ac=AD_20140827HP_OpioidToolkit14.

Ms. McElhaney has disclosed no relevant financial relationships.

PAINWeek 2014. A Call to Arms on the Heroin Epidemic. Presented Thursday, September 4, 2014.

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