Expanded Naloxone Access Could Help Curb Opioid Deaths

The Role of Psychiatrists as Naloxone Advocates

As rates of overdose deaths from prescription opioids and heroin quadrupled between 1999 and 2014, opioid sales increased along with them.
As rates of overdose deaths from prescription opioids and heroin quadrupled between 1999 and 2014, opioid sales increased along with them.

As rates of overdose deaths from prescription opioids and heroin quadrupled between 1999 and 2014, opioid sales increased along with them. A record number of people died in 2014 from drug overdose, which now tops the list of leading causes of adult death from injury. More than 3 in 5 of these deaths involved an opioid, and over half of them resulted from prescription opioids.1 At the same time, there has been a growing push for widened access to naloxone, an opioid antagonist that reverses the respiratory depression characteristic of opioid overdose. Since Naloxone is not a controlled substance, it carries no potential for abuse, and it has served as the standard antidote to opioid overdose by US medical practitioners for over 40 years.2

“Medical experts first called for the provision of naloxone outside of the medical setting in the early 1990s,” and by the mid-2000's, “community-based programs in several US states… had begun distributing naloxone and overdose prevention and response training to people who use drugs and bystanders likely to witness an overdose,” according to a case study published in 2015 in Harm Reduction Journal.2 By June 2014, there were 644 community-based overdose education and naloxone distribution (OEND) programs in the US, with a reported 26,463 overdose reversals.

Despite their demonstrated success and clear endorsement from agencies such as the World Health Organization, the American Medical Association, and the American Psychiatric Association, these programs generally operate on very limited funding. “These community-based programs have access to many of the highest risk people that would otherwise be difficult to reach, and programs like these need financial and community support to broaden the adoption of OEND,” Alexander Y. Walley, MD, MSc, a co-author of the 2015 study, told Psychiatry Advisor. Dr Walley is an assistant professor of medicine at the Boston University School of Medicine and the medical director of both the Opioid Treatment Program at the Boston Public Health Commission and the Massachusetts Department of Public Health's Opioid Overdose Prevention Program.

His research has also shown that communities that implement OEND have lower death rates from opioid overdose compared with communities without OEND, and other studies also show significant numbers of overdose reversals with naloxone programs.3-5 The researchers also found that OEND can be successfully distributed among people who use drugs–and effectively administered even by untrained rescuers–and that those who return for naloxone refills do not increase their subsequent drug use, as some skeptics have feared they might.

“Furthermore, naloxone access needs to be mainstreamed into medical and addiction treatment settings in which high risk people and their social networks can be reached, such as emergency departments and detoxification facilities,” he says, adding that OEND should also be targeted to individuals recently released from incarceration, as they comprise the population with the highest risk. One setting that makes a promising target for efforts at expanded naloxone access is the pharmacy, according to the 2015 case study. “Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the US and globally,” and pharmacies “provide a high-yield setting where patient and caregiver customers can access” OEND, wrote the authors.

The paper describes a pharmacy-based naloxone program in Rhode Island, which began in 2011 and vastly expanded in 2013. While most surrounding states had significant increases in overdose deaths since then, Rhode Island only had 7 additional deaths in 2014 vs 2013. Though causal inferences cannot be made, especially because of concurrent efforts to increase naloxone access via emergency departments and law enforcement personnel, these findings are promising. “We can address stigma and patient safety best with improved access to naloxone across the care continuum,” Traci C. Green, PhD, MSc, another co-author of the study, told Psychiatry Advisor. “Pharmacy based naloxone also can help with geographic reach and sustainability of naloxone access in the community, which may be constrained if naloxone is limited only to community programs, or to urban centers,” says Green, a senior scientist and deputy director of Boston Medical Center Injury Prevention Center, and associate professor of emergency medicine at Boston University and Brown University.

Some of the key barriers to the widespread adoption of pharmacy-distributed OEND programs in the US are practical ones–such as stocking and ordering naloxone and training staff on its provision, and others include issues like discomfort in discussing death and addiction risk with patients. She and colleagues found that pharmacists and patients indicate a preference for a universal prevention approach in which individuals can opt out of receiving naloxone but everyone is offered the drug based on signs of clear medication risk. “For instance, we know that patients receiving high doses of opioid pain medications or co-prescribed benzodiazepines and opioids are at high risk of overdose,” Green explains. If a prescription monitoring program identifies this medication combination, it could cue an automatic offer of naloxone to the patient.

To expand the provision of naloxone, including via pharmacy-based naloxone programs and other viable partners, it needs to be adopted as a standard of care by systems of medical and pharmacy care, says Green. “We have a serious epidemic on our hands. It's not one or the other, it's 'all of the above' that is needed for naloxone access in our communities,” says Green, who notes that psychiatrists can be leaders and valued partners in these efforts.

Prescribing naloxone is permitted in every state, and many allow standing orders between physicians and pharmacies. Partnering with a particular pharmacy to serve as a standing order pharmacy could greatly expand naloxone access for patients. “Encourage your colleagues to prescribe naloxone, or if you are living in a state with pharmacy access, recommend naloxone to your patients and encourage them to visit the pharmacy to get it,” she recommends.

A 2016 study by the National Institute on Drug Abuse and other federal agencies shows that the number of naloxone prescriptions filled by US pharmacies increased 1170% between 2013 and 2015, suggesting that “prescribing naloxone in the outpatient setting complements traditional community-based naloxone programs,” the authors concluded.6 Interested providers can access relevant tools, including a continuing medical education course about naloxone prescription, at www.prescribetoprevent.org. “As a patient told me the other day,” Green says, “it's better to have it and not need it than to need it and not have it.”

 

References

1. Centers for Disease Control and Prevention. Injury prevention & control: opioid overdose. Retrieved on 6/24/16 from http://www.cdc.gov/drugoverdose/data.

2. Green TC, Dauria EF, Bratberg J, Davis CS, Walley AY. Orienting patients to greater opioid safety: models of community pharmacy-based naloxone. Harm Reduct J. 2015; 12: 25.

3. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013; 346:f174.

4. Rowe C, Santos GM, Vittinghoff E, Wheeler E, Davidson P, Coffin PO. Predictors of participant engagement and naloxone utilization in a community-based naloxone distribution program. Addiction. 2015; 110(8):1301-10.

5. Rowe C, Santos GM, Vittinghoff E, Wheeler E, Davidson P, Coffin PO. Neighborhood-level and spatial characteristics associated with lay naloxone reversal events and opioid overdose deaths. J Urban Health. 2016; 93(1):117-30.

6. Jones CM, Lurie PG, Compton WM. Increase in naloxone prescriptions dispensed in US retail pharmacies since 2013. Am J Public Health. 2016; 106(4):689-90.

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