New guidance: Who can benefit from naloxone co-prescribing

Andis Robeznieks
Senior Staff Writer
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The opioid epidemic took more than 33,000 lives in 2015, according to the Centers for Disease Control and Prevention (CDC). More would have died if not for the wider availability and use of the opioid-overdose antidote, naloxone.

The AMA Opioid Task Force recently issued updated guidance encouraging physicians to consider co-prescribing the drug when clinically appropriate for patients who are at risk for opioid overdose or might be in a position to help someone else at risk.

Naloxone provides “second chance”

"If it were not for naloxone, it is likely that many thousands more would be dead from an opioid-related overdose," said Patrice A. Harris, MD, chair of the AMA Opioid Task Force. "We know that naloxone—by itself—will not reverse the nation's opioid epidemic, but it is a critical component that saves lives and provides a second chance."

Sarah Wakeman, MD, medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Boston’s Massachusetts General Hospital, agrees.

“Co-prescribing naloxone is important to ensure all people being prescribed opioids at risk for overdose have this lifesaving medication at home, similar to how we might think about co-prescribing glucagon to someone with insulin-dependent diabetes,” Dr. Wakeman, a Harvard Medical School assistant professor of medicine, said in an email. “But it is also important because it gets more naloxone out into the community and educates people about how to prevent and respond to an overdose.”

Patient selection

The updated guidance includes several important questions that physicians should consider to help determine whether they should co-prescribe naloxone to a patient—or to a family member or close friend of the patient.

  • Is the patient receiving a high dose of opioids?
  • Does the patient also have a prescription for a benzodiazepine?
  • Does the patient have a history of substance-use disorder?
  • Does the patient have an underlying mental health or other medical condition that makes him or her more susceptible to overdose?

In addition to providing “a tangible option for care,” the task force’s guidance notes that the decision to co-prescribe can also be used to initiate a discussion with patients on the risk of overdose, the stigma a patient may be facing, and broader issues around substance-use disorder treatment.

“I've found that generally patients are quite open to being prescribed naloxone and it can open up an important conversation about overdose risk. Not infrequently, the conversation ends up eliciting a story from a patient about a loved one who is suffering from opioid-use disorder,” Dr. Wakeman said. “In the midst of the current epidemic nearly everyone knows someone dealing with this illness and even individuals not at risk themselves are eager to have a way to help save a life.”

The document also includes links to multiple resources for physicians to use in their practice, such as recommendations for use in different settings, best practices and product comparisons.

Barriers to broader use

No one should die from an overdose, Dr. Wakeman said.

“We have a reliable antidote which laypeople can be trained to administer,” she said. “Even more importantly, we have effective treatment for opioid-use disorder, including medications like buprenorphine which have been shown to reduce the risk of death by more than 50 percent.”

Two issues that could hinder co-prescribing are a lack of awareness and steep price increases in the cost of naloxone.

“The first issue is getting physicians aware of the need for co-prescribing and comfortable with the logistics—this will hopefully be greatly furthered by the AMA task force recommendation,” Dr. Wakeman said. “As the crisis of opioid-related deaths has soared, so has the price of naloxone. There is no reason other than profit to justify the price hike in all forms of naloxone. Although many insurance plans now cover naloxone, there can be high co-pays for patients which can be a huge barrier.”

In June, the AMA House of Delegates modified existing policy relating to the accessibility of naloxone to emphasize the need for the opioid-overdose antidote to be affordable.

Studies cited in the task force’s guidance supports naloxone’s lifesaving impact.

There were 26,463 naloxone-assisted overdose reversals reported from 1996 through June 2014, according to a survey of managers in U.S. organizations that provide naloxone to laypeople. The results were published in the CDC’s Morbidity and Mortality Weekly Report.

Another study showed naloxone’s effectiveness in preventing emergency-department visits. Of 1,985 patients being treated for chronic pain at six safety-net primary care clinics in San Francisco found that those co-prescribed naloxone had 63 percent fewer opioid-related ED visits a year after receiving the prescription when compared with those who were not prescribed naloxone.

When states pass laws allowing laypeople to administer naloxone or providing immunity from prosecution to people calling for medical assistance, there is a 9 to 11 percent decrease in opioid-related deaths, according to a National Bureau of Economics Research study using National Vital Statistics System data from 1999–2014.

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