The antidote: 3 things to consider when co-prescribing naloxone
Community distribution, use by first responders and co-prescribing of the opioid antagonist naloxone has been shown to reverse prescription opioid and heroin overdose and save lives across the country. But how do you explain the safety benefits of a naloxone prescription to your patients without the stigma that overdose carries? Learn how one physician approaches this issue in a way that helps patients understand that co-prescribing naloxone is for their own safety and well-being.
Naloxone has saved tens of thousands of lives and will save many more as its availability continues to increase throughout the country. Some patients with chronic pain benefit from opioid treatment, but these medications carry certain risks, including respiratory depression, so co-prescribing naloxone for patient safety is an important tool for physicians.
Recently, a study surveyed more than 100 prescribers in clinics that were dispensing naloxone in San Francisco, and about 80 percent had co-prescribed naloxone, said the study’s lead author Phillip O. Coffin, MD, director of substance use research at the San Francisco Department of Public Health and an internal medicine and infectious disease specialist. “99 percent felt that they were likely to prescribe naloxone in the future.”
How to talk about naloxone with your patients
Dr. Coffin said routinely co-prescribing naloxone is important not just for patients physicians think may overdose, but also for safeguarding others who may have access to these medications.
“No. 1 is, yes, that person may be at risk of overdose,” he said. “But No. 2 is the person may have enough opioids at their house that somebody else in their life or community could access those and be at risk of overdose.”
When framing the conversation with patients, emphasize that opioid medications carry certain risks, not that the patients themselves are risky, Dr. Coffin said. “That’s important to help reduce the stigma and help make patients feel like they’re not being targeted or somehow accused of being out of control with their medications.”
Here are three important things Dr. Coffin considers when co-prescribing naloxone:
Talking about overdose
“It is critical not to start out with the word ‘overdose,’” Dr. Coffin said. “The word ‘overdose’ to a patient, and to many providers, means either injecting heroin or taking a whole bottle of pills. That’s not what we mean as a medical system when we talk about the risk of overdose with opioids. What we mean is when there are more opioids in your body at a given time than your body can handle at that time.”
“That might mean you have sleep apnea, and you stop using your C-PAP machine and so the opioids that you take could suppress your respiration too much for you to breathe enough that night, and you might effectively overdose,” he said. “It might mean you get a bout of pneumonia, and you’re not breathing as well …. It might mean that your five-year-old grandkid gets into your medicine cabinet.”
“It can mean a lot of things, but it doesn’t mean that you’re a bad person or that you’re doing something wrong,” he said. “It means that these are risky medications, and we want to make sure that the antidote is nearby in case something happens to you or someone in your social network.”
The risks involved
Bringing naloxone into the conversation can help patients recognize that the medications they’re using can be dangerous, Dr. Coffin said. “Once you’re prescribed opioids, it’s hard to understand that this is risky. ‘Why would my doctor prescribe this to me if it’s risky?’ You can talk about the risks of opioids, but we know patients don’t really hear that.”
“When you pair that with an actual prescription, with an actual intervention, it helps to impress upon the patient that … my goal in working with you with opioids is to maximize your safety and well-being.”
“There’s that need to have some sort of tangible intervention that can really solidify the counseling that’s provided in the clinical interaction,” Dr. Coffin said. “Naloxone can serve that purpose in addition to the more direct potential benefits of reducing mortality.”
Who should get naloxone
There are two contexts in the distribution of naloxone, Dr. Coffin said. “One is the context of distributing it to drug users, and that’s usually through needle exchange programs,” he said. “That’s where it’s most likely to be used to reverse an overdose. Around 20 percent of the naloxone handed out at these programs ends up being used to reverse an overdose.”
The next context for distribution is co-prescribing naloxone to patients—and that is much different. “You’re working with patients who are prescribed opioids, and they perceive their risk of overdose to be low or nonexistent,” Dr. Coffin said. This situation cannot be approached in the same way as handing out naloxone at a needle exchange program.
“When you’re in a clinic, … patients don’t perceive that they’re at risk and they’re not hanging out with a bunch of people injecting opioids,” he said. “They’re not overdosing all the time, or perhaps they don’t see themselves as overdosing.” “In fact, we did interview some patients who … [were given] naloxone by the paramedics after taking opioid medications, but they didn’t perceive it as an overdose,” he said. “Many of our patients who had overdosed perceived the event as an adverse reaction to their medication. That’s a critical distinction that patients make … they see this as a bad reaction like having anaphylaxis to a medication or a severe rash.”
In the clinic, “you have the added benefit of the clinician interaction,” he said. “You can use that naloxone prescription as a way to get in there and talk about broader opioid safety issues.”
Learn more about physicians’ efforts to end the opioid epidemic
- Read Dr. Coffin’s advice for talking about substance use disorders with your patients
- Learn 3 steps for your first conversation with a patient with a substance use disorder
- Find out how one state made naloxone available for its entire population
- Learn what the AMA Task Force to Reduce Opioid Abuse recommends for physicians to reduce stigma and increase use of medication-assisted treatment.
- Read a call to action for physicians to turn the tide of the opioid epidemic, and watch a video message from AMA President Steven J. Stack, MD.
Are you treating patients with substance use disorder? Send us an email or comment below to tell us how you do it and how your practice is helping patients.