Naloxone Prescribing: 5 Things to Know

Debra Houry, MD, MPH

Disclosures

October 30, 2019

Editorial Collaboration

Medscape &

Almost 400,000 people died from an opioid overdose in the United States between 1999 and 2017. On average, 130 Americans die every day from an opioid-involved overdose. In addition to prevention efforts, there is a life-saving medication that can reverse the effects of an opioid overdose.

1. Naloxone can be dispensed without a prescription.

Naloxone is a medication that binds to opioid receptors in the brain, reversing the toxic effects of an overdose. It can be given by intranasal spray and by intramuscular, subcutaneous, or intravenous injection.

Healthcare providers, including pharmacists, play a critical role in ensuring that patients who might experience or respond to an overdose receive naloxone. Currently, all 50 states and the District of Columbia have standing order laws or other regulations or collaborative practice agreements that allow pharmacists to dispense naloxone without a patient-specific prescription. Several states also require physicians to co-prescribe naloxone when prescribing high-dose opioids (defined as a daily morphine milligram equivalent (MME) dose of ≥50 MME). Both standing order and co-prescribing laws can increase naloxone dispensing in pharmacies and help reduce opioid overdose deaths.

2. Naloxone remains underprescribed and underused.

We're making progress. From 2017 to 2018, high-dose opioid prescriptions decreased by 21% while naloxone prescriptions dispensed from US retail pharmacies more than doubled. A second study focusing on Medicare Part D also showed a recent increase in naloxone coprescribing to patients receiving opioid pain medications, particularly to patients receiving high doses of opioids or opioids and benzodiazepines concomitantly.

Both studies reached the same conclusion, however: Most people who may need naloxone are not getting it. Only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions nationwide in 2018. If each provider had considered offering naloxone to every patient (or a family member) receiving a high-dose opioid prescription, as recommended in the CDC guideline, nearly 9 million prescriptions for naloxone could have been dispensed in 2018.

Naloxone prescribing also varies widely among physician specialties. The number of naloxone prescriptions dispensed for every high-dose opioid prescription was low among specialties that frequently prescribe high-dose opioids compared with other specialties. In other words, primary care and pain medicine physicians prescribed less naloxone (1.3 and 1.5 per 100 high-dose prescriptions, respectively) compared with addiction medicine physicians (12.2) and psychiatrists (12.9). Additionally, despite being the most likely physicians to treat an overdose, emergency medicine physicians prescribed naloxone at a rate of only 2.8 per 100 high-dose opioid prescriptions.

3. Coprescribing naloxone is recommended for patients at risk for opioid overdose.

The CDC Guideline for Prescribing Opioids for Chronic Pain recommends that healthcare providers consider offering naloxone to patients at risk for opioid overdose. Risk factors for opioid overdose include taking high daily dosages of prescription opioids, using benzodiazepines concurrently with opioids, and having a history of substance use disorder.

Emergency departments have an important opportunity to equip individuals responding to or experiencing an overdose and should consider prescribing naloxone at discharge to at-risk patients and their loved ones.

Department of Health and Human Services Guidance for Naloxone Prescribing and Coprescribing

Patients prescribed opioids who:
  • Are receiving opioids at a dosage of 50 morphine milligram equivalents (MME) per day or greater (the CDC's MME calculator can be accessed here)

  • Have respiratory conditions such as chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (regardless of opioid dose)

  • Have been prescribed benzodiazepines (regardless of opioid dose)

  • Have a nonopioid substance use disorder, report excessive alcohol use, or have a mental health disorder (regardless of opioid dose)

Patients at high risk for experiencing or responding to an opioid overdose, including individuals:
  • Using heroin or illicit synthetic opioids, or misusing prescription opioids

  • Using other illicit drugs such as stimulants, including methamphetamine and cocaine, which could potentially be contaminated with illicit synthetic opioids like fentanyl

  • Receiving treatment for opioid use disorder, including medication-assisted treatment with methadone, buprenorphine, or naltrexone

  • With a history of opioid misuse and who were recently released from incarceration or other controlled settings where tolerance to opioids has been lost

4. Providers need training and education on naloxone and opioid use disorder.

In order to prescribe naloxone to patients at risk for opioid overdose, providers must first be trained to identify the risk factors for opioid overdose and then counsel patients and loved ones on naloxone use and access. This includes identification of candidates and initiation of or referral to medications for opioid use disorder treatment (ie, buprenorphine, extended-release naltrexone, or methadone).

Providing this additional instruction will create a large and well-trained provider pool on the front line of care to treat this chronic disease. CDC's interactive online training series aims to help healthcare professionals apply CDC guideline recommendations and includes a module on opioid use disorder.

Providers and hospitals/clinics may also need assistance in using technology, such as electronic health records, to its fullest capabilities. Health systems can consider proactive approaches such as setting up coprescribing prompts. Electronic health records can also support system-level quality improvement measures for naloxone. For example, health systems can identify how often patients on long-term opioid therapy were counseled on the purpose and use of naloxone, and either prescribed or referred to obtain naloxone.

5. Helping patients identify places that dispense naloxone can increase the number of people who carry it.

For decades, emergency medical service providers, first responders, and emergency department clinicians have administered naloxone in cases of suspected drug overdose. Community-based organizations have also offered naloxone through education and distribution programs for many years. Now, the US Surgeon General is calling for more individuals to carry naloxone, including family, friends, and those who are personally at risk of experiencing or responding to an opioid overdose.

Those who are at risk for opioid overdoses and their loved ones should be educated on what naloxone is, how to use it, and where to get it, and be advised to carry it with them once they have it. Together, we can work to help those who have experienced opioid overdose.

Providers can help identify patients who might benefit from naloxone as well as help patients gain access to naloxone through the following:
  • Use the state's prescription drug monitoring program (PDMP).

    1. PDMPs can help identify patients who may be at risk for overdose and alert providers to potentially lifesaving information and interventions.

  • Link patients with naloxone resources.

    1. Find out if the state permits pharmacists to prescribe naloxone independently or dispense naloxone under a standing order or collaborative practice agreement.

    2. Provide additional resources to access naloxone from community-based organizations.

  • Support the patient.

    1. Consider prescribing naloxone to individuals who are at elevated risk for opioid overdose and to their friends and family.

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