Reflections on PAINWeek

In the battle to reduce deaths linked to prescription opioids and heroin, the practice of distributing naloxone to opioid users is gaining favor. Naloxone is a quick intervention to reverse the effects of opioids when an overdose has occurred. In its recent toolkit to avoid opioid overdoses, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommends easy access to naloxone for prescribers, first responders, community members and people who have previously survived an overdose or who are at risk for one as well as their families [1].

This promises to be a beneficial policy, as the research is clear that as a public-health measure, naloxone can save lives. Respondents to a survey by the Harm Reduction Coalition from 48 community programs representing 188 local programs in 15 states and the District of Columbia reported 10,171 overdose reversals using naloxone between 1996-2010 [2]. Recent community-based programs include Project Lazarus and Operation OpioidSAFE in North Carolina, which include prescribing naloxone along with opioids when patients meet high-risk criteria [2].

Wider access to naloxone is not without complications, though. As an anesthesiologist I have observed that naloxone can induce heart failure in someone who is opioid dependent. This is due to the epinephrine surge that occurs with naloxone and occurs only in those who are physically dependent on opioids. A few people have died from “rapid detox,” a process of infusing naloxone in physically dependent people under anesthesia.

Still, there is so much potential benefit in having an antidote close by, and the almost 17,000 deaths linked to opioid analgesics in 2010 along with greater heroin abuse in many areas indicate that many more people will be saved by naloxone than harmed [2]. Furthermore, the FDA approval of an auto-injector, specifically mentioned in the SAMHSA toolkit, which does not require special training and can deliver a naloxone dose through clothing on the outer thigh muscle. This development could make administration safer and reduce the spread of disease, such as AIDS or hepatitis, that is a risk of needle injections. Disputing the common belief that the “safety net” of naloxone may increase illicit use, in which heroin users were trained to give CPR and administer naloxone resulted not only in saved lives but decreased heroin use, an unexpected benefit [3].

Cost will be an issue as injectable naloxone runs only about $6 a dose and the cost of the auto-injector, which can deliver a low dose through clothing is not yet known [2]. State substance abuse agencies may use Substance Abuse Prevention and Treatment Block Grants to purchase and distribute naloxone, and SAMHSA is studying other funding sources as well. Education is important with naloxone as effectiveness depends on having someone nearby who knows where the naloxone is stored and how to administer it.

SAMHSA states the specific high-risk conditions for which naloxone should be made available. They are [2]:

·Long-term management of chronic pain with prescription opioids

·The moment of changing from one type of opioid medication to another

·Discharge from emergency medical care following opioid intoxication or poisoning

·Suspected or confirmed prior substance abuse with opioids

·Reduced opioid tolerance that follows detoxification or other period of abstinence

·Recent release from incarceration of a past user or abuser of opioids, a scenario that combines reduced tolerance with high risk of relapse

Some additional times to consider co-prescribing naloxone with an opioid prescription include [4]:

·When patients are obese and are also on benzodiazepines for anxiety or insomnia, as their breathing may be compromised

·Whenever extended-release/long-acting opioids are prescribed

·When the opioid prescribed is methadone

·When a person has some kind of respiratory compromise

There are many situations in which naloxone can save lives. Ideally, naloxone should be considered part of the universal precautions for assessing risk and engaging in ongoing management whenever opioids are prescribed for chronic pain [5]. Consider also that the Official Journal of the American Academy of Pediatrics reports that exposures and poisonings in children are rising and linked to opioid medications prescribed to adults in the household [6].

Naloxone should be considered a potentially life-saving drug like ipecac, and, as such, it may be important to have naloxone in any home where any opioid is being used. Naloxone is not a perfect solution, however, and we must continue to push for safer, non-addictive analgesics that don’t cause respiratory depression at therapeutic doses. Until the analgesics of tomorrow materialize, naloxone could save lives today.

References

  1. Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
  2. Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone – United States, 2010.
  3. MMWR Morb Mortal Wkly Rep. 2012;61(6):101-5
  4. Seal KH, Thawley R, Gee L, et. al Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. J Urban Health. 2005;82(2):3030–11
  5. Webster LR. Eight principles for safer opioid prescribing. Pain Med. 2013;14(7):959-61.
  6. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-12.
  7. Burghardt LC, Ayers JW, Brownstein JS, Bronstein AC, Ewald MB, Bourgeois FT. Adult prescription  drug use and pediatric medication exposures and poisonings. Pediatrics. 2013;132(1):18-27.

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