Prescribing Naloxone to Prevent Overdoses
Seddon R. Savage MD, MS (adapted by M. Bidgood-Wilson, 10/11/2015).
A recently passed New Hampshire law HB 2711means that New Hampshire providers
can now prescribe, dispense or distribute naloxone not only to patients at risk for opioid
overdose, but also to family members or friends concerned about risk of overdose in a
loved one who is not a patient of the provider. This means, for example, that a provider
may prescribe naloxone to a father or mother to use in the event of an overdose by a
heroin-using daughter who is not a patient of the provider.
( http://www.gencourt.state.nh.us/legislation/2015/HB0271.html)
The legislation passed in May also confers immunity from civil, criminal and
professional liability to the prescriber, dispenser, and/or administrator of naloxone in the
event of adverse outcomes related to use of the prescribed naloxone. While naloxone is
generally regarded as a safe drug without any clinically significant effects if given to
persons not using an opioid, it produces opioid withdrawal in persons using opioids.
Withdrawal is usually uncomfortable, but medically benign. However, relatively rare
complications of withdrawal can include combativeness related to anxiety and
disorientation, tachycardia/hypertension creating risk in persons with serious
cardiovascular disease, and unmasking of hypoxic seizures. The risks associated with
these must be understood against the likelihood of death if naloxone is not administered.
Context
Naloxone has been routinely used for decades to reverse opioid overdoses in hospital
emergency rooms and by some EMTs in the field. With rising opioid overdose deaths
across the country, its use in diverse community settings has rapidly expanded and
families and friends of persons at risk for overdose have understandably sought access to
naloxone for use in an overdose emergency with a loved one.
In New Hampshire all levels of EMT personnel now carry naloxone for use in opioid
overdose emergencies. Recent legislation authorizes training and use by law enforcement
as well, but actual implementation will be elective by different jurisdictions.
An FDA study and report published in April 2012, suggests that over-the-counter (OTC)
availability of naloxone may occur in the future but is not likely for at least several years.
In the meantime, in some states, such as Rhode Island, naloxone is available OTC at
some chain pharmacies including Walgreens and CVS, through collaborative practice
agreement between state providers and pharmacists. The new New Hampshire law
stipulates that prescribers may make naloxone available through standing orders, but at
press time for this article, communication with the Attorney General’s office was
ongoing to fully understand what this can mean in practice.
Considerations in prescribing
There are a few issues to be considered in prescribing naloxone to opioid users and/or
their families or loved ones. Detailed and reliable information for prescribers and
pharmacists is available on all of these at the excellent website:
www.prescribetoprevent.org
Who should receive prescriptions for naloxone? There are two schools of thought, both of
which are supported by the new law so providers can determine what is right in their
judgment:
One perspective suggests it should be given to persons identified as being at high risk of
overdose. Some risk factors include:
Current or past opioid use disorder including use of heroin or misuse of
prescription medications.
Patients prescribed opioids for pain who have:
Misused their opioids,
Current or past history of any substance disorder,
Presence of significant psychiatric disorder,
Opioid dose greater than 50-100mg morphine equivalents, or
Co-occurring medical risk factors: pulmonary dysfunction, renal or
hepatic disease, central nervous system compromise or others.
The other perspective suggests it should be routinely provided along with all opioid
prescriptions, similar to providing glucose tablets to persons on insulin, as well as to
persons known to use street opioids. Arguments are:
What constitutes “high risk “is not certain; and
The ability of clinicians to accurately identify risk is limited.
A number of forms of naloxone are currently available. Each may or may not be
covered by different insurances.
Injectable vial and syringe form (cheap but perhaps challenging for
stressed lay persons to use in an emergency and risk of needle stick)
Intranasal naloxone (inexpensive and available in kits that can be ordered
by pharmacies, no risk of needle stick, not FDA approved but widely used and
studies support nearly similar efficacy to intramuscular)
FDA approved auto-injector (Evzio - relatively expensive but with long
shelf-life, no needle stick risk, user friendly audio instructions)
Pharmacy availability may be limited.
Have someone in your office identify a pharmacy that carries naloxone
and/or
Provide information to your local pharmacy regarding options available for
ordering (see www.prescribetoprevent.org).
www.prescribetoprevent.org as prepared handouts:
o Need to call 911 for help and/or transport to hospital due to short acting nature of
naloxone,
o Identification of opioid overdose,
o Rescue positioning and breathing,
o When and how to use naloxone, and
o Possible side effects of naloxone and how to manage.
sense of safety and encouraging more opioid use?
o There are no studies directly assessing this concern.
o However, overdoses may occur for diverse reasons most of which would not be
changed by the presence of naloxone.
absence of naloxone.
-occurring medical problems experience overdose as a result of
medical issues, not intentional overuse.
of symptoms.
o On the other hand, some persons conceivably might experiment with opioids they
might not otherwise misuse due to a sense of safety in the presence of naloxone.
As with all medical care, prescribing of naloxone requires assessment of the potential
risks and benefits; in most contexts, the availability of naloxone is expected to reduce risk
and save lives.