COMMENTARY

Time for Honest Discussions About Naloxone

US Surgeon General and Director of CDC's National Center for Injury Prevention and Control

Vice Admiral Jerome M. Adams, MD, MPH; Debra Houry, MD, MPH

Disclosures

October 30, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Vice Admiral Jerome M. Adams, MD, MPH: Hello, Medscape community. I'm United States Surgeon General Dr Jerome Adams.

Debra Houry, MD, MPH: I'm Dr Deb Houry, an emergency physician and Director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention.

Adams: Today we're here to discuss naloxone, the opioid overdose reversal drug. We know that naloxone provides an opportunity to save lives and to be a bridge to treatment and recovery. In 2017, roughly 48,000 of all US drug overdose deaths involved opioids. That is why a critical component in reducing drug overdose deaths is increasing the availability and targeted distribution of naloxone. Despite the huge increase in naloxone prescribed in recent years, far too little is being distributed in many areas of the country.

Who Should Be Prescribed Naloxone?

Adams: Who should be getting naloxone?

Houry: Anybody who is at risk for overdose. This includes people who are on high-dose opioid prescriptions, anyone using any type of illicit or illegal drug (because we're seeing methamphetamine and cocaine being mixed with things like fentanyl), and those on a benzodiazepine or muscle relaxants.

Adams: You mentioned methamphetamine. Is that related to the evolution of the opioid overdose epidemic?

Houry: We're starting to see an increase in methamphetamine and cocaine overdoses. And many times that is because it's been mixed with fentanyl. I think about two thirds of cocaine overdoses have fentanyl or opioids in them.

Adams: Wow. What would you say to doctors and others thinking about the particular profile of someone who has opioid-use disorder?

Houry: It's so important to have honest conversations. Ask everybody whether they are using any drugs, and say to people on an opioid prescription, "You could be at risk for an overdose, so let's consider prescribing naloxone for you."

Barriers to Obtaining Naloxone

Adams: What are some of the barriers for a pharmacist, doctor, or anyone who wants to get naloxone?

Houry: I think back just to my own clinical practice. I don't always think about taking that extra step to write that prescription. We need to think about this for all of our patients. In Ohio, a system automatically links naloxone with any opioid prescription through the electronic health record. That really helps physicians. For patients, it's about knowing where to get it and knowing that you need it. Pharmacists and physicians really need to educate patients about that.

Adams: Great. I highlighted in an advisory last year—the first advisory from the Surgeon General's office in over 13 years—that people should know about naloxone and where to obtain it, because any one of us can save a life.

Improving Access to Naloxone

Adams: What works to improve access and availability to naloxone? What are some best practices that we as physicians should know about?

Houry: I think one is having standing orders. As a former state health officer, you could have had a standing order in your state.

Adams: I had a standing order in my state.

Houry: Perfect. The one I'm familiar with is where a patient goes up to the pharmacist and says, "I believe I need naloxone because I'm on a high-dose opioid prescription, or, my doctor recommended that I get it."

Adams: It's important that everyone understands that the standing orders are available but they are different in every state. That is why it's important to know the laws in your state.

Good Samaritan Laws

Adams: Could you also talk a little bit about the Good Samaritan law?

Houry: This comes into play when you are trying to help someone on the street. Some people worry that if they are trying to help somebody and reverse their overdose, they might get arrested if they were using at the same time. Good Samaritan laws protect people from that. We want you to do the right thing for the person in front of you and call 911.

What More Should Providers Know and Do?

Adams: What should our physicians and providers in particular know about naloxone? What more could we be doing?

Houry: I think [they should be] getting naloxone out there into the hands of those that need it. I work in a medication-assisted treatment clinic. Now when I write my buprenorphine prescription, I get a prompt that says, "Does this patient need naloxone?" If I say yes, it goes directly to the pharmacy. Really think about how to co-prescribe it for that patient at risk. And it's not just for the patient at risk. As you were talking about with your advisory, does someone need naloxone because their family member is at risk for overdose?

Adams: Pharmacists are part of the team that is necessary to make sure we're getting naloxone into the hands of more people. Can pharmacists dispense naloxone?

Houry: Pharmacists can dispense naloxone with a standing order. If a patient asks for naloxone saying they are on a high-dose opioid or other medication contained in that standing order, pharmacists can dispense it. Massachusetts has a really neat practice now that includes a remote dispensing law. So now if a pharmacist is at a community event or something like that and wants to dispense naloxone, they are able to do so.

Adams: One of the things you hear about with naloxone is that so often people get resuscitated or revived, but then we send them back out into the arms of the drug dealers who put them in the situation in the first place. You and I have co-written a journal article[1] where we talk about the need for more providers to be [aware of that] and to be willing to write for medication-assisted treatment. Can you talk more about that?

Houry: To your point about naloxone, I think after you resuscitate somebody is a great opportunity to then talk with the patient. "We saved your life today. We don't want this to happen again, so how can we get you into treatment?" You can start medication-assisted treatment in the emergency department for somebody so that they get linked to treatment immediately and don't start going through withdrawal.

Adams: I've found out that many physicians don't know what the available take-home versions of naloxone look like. We physicians tend to think about injectable versions. Can you tell us a little bit about what we have here?

Houry: Fortunately, I know the answer. This is intranasal. I would squirt it in somebody's nose. This is very easy to do because there is no injection or anything like that.

Adams: And it's easy to describe to your patients and they can be comfortable with it. That is the Adapt version.

We also have the Evzio version that talks to you. It literally is that easy. I think it's critically important that we as providers understand how easy these are to use so we can help overcome patient consternation and fears about using these products.

Houry: And this helps decrease the stigma and promotes it. I was at a conference that you were speaking at, and you had it with you. It really showed how it's important to always carry it with you, because you can't save that life if you don't have it with you.

Adams: Exactly. We've got to walk the talk, and that is one of the big reasons we're here today. Anything else you'd add for your colleagues before we close?

Houry: It's just that we all really can make a difference. The advisory that your office put out and all that you've been messaging has helped. Health and Human Services also recently issued increased guidance to increase thinking about all the different types of patients that could benefit from naloxone. We need to continue to talk about naloxone and make sure patients are getting it.

Adams: Great. And as you mentioned, we need to overcome that stigma. I've often said that stigma is one of the biggest killers out there.

In closing, I'd say that everyone has an important role to play to improve naloxone prescribing, dispensing, and to ultimately combat the opioid epidemic. We must also recognize and address the individual, family, and community dynamics that have enabled the opioid crisis to take root and grow. This is essential for solving the opioid crisis in the long term. For more information about the steps that you can take to combat opioid misuse, I encourage you to go to SurgeonGeneral.gov. I also encourage you to share my digital postcard, which lists five steps that everyone can take to help respond to the opioid epidemic. Only by working together can we end this crisis.

Thank you again, Dr Houry, for joining me, and thanks to our Medscape listeners and viewers out there. Please go to SurgeonGeneral.gov. Do your part, because all of us have a role to play in saving lives.

Vice Admiral Jerome Adams is the US Surgeon General. In 2018, he released a Surgeon General's advisory on naloxone and opioid overdose.

Dr Debra Houry is director of the National Center for Injury Prevention and Control at CDC. She practices in a medication-assisted treatment clinic.

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