Co-prescribing naloxone with opioids

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When authorized medical personnel prescribe two or more medications together for the same condition or disease to the same patient, it is known as co-prescribing. When clinicians prescribe the opioid overdose drug naloxone (Brand name: Narcan) to patients in conjunction with the patient's opioid prescriptions, or to patients at risk for opioid overdose, it is called a naloxone co-prescription. Due, in part, to the opioid epidemic in the United States, there are currently both a state-level and nation-wide movement in the medical and public policy fields to encourage, and sometimes require, naloxone co-prescribing. The U.S. government has issued guidelines recommending co-prescribing naloxone along with opioids. Some co-prescribing, e.g., the practice of co-prescribing benzodiazepines and certain opioid medications to patients, has been cause for concern due to the high risk of opioid overdose.

Co-prescribing naloxone with opioids is supported by the World Health Organization, U.S. CDC, and Substance Abuse and Mental Health Services Administration (SAMHSA). [1] In 2020, The Pew Charitable Trusts released research findings which show that increased access to naloxone saves lives, and recommends co-prescribing as a way to lower the number of overdose fatalities. [2]

Background

The illegitimate use of opioids in the United States became an "epidemic" in the early 21st century. The Mayo Clinic Proceedings describes the epidemic as "...the most serious and most important public health crisis today." The consequences of the calamity are not only significant deaths due to opioid overdose, but also a descending trend in health and people's sense of well-being throughout the country. Increased use of naloxone, particularly the nasal spray version, Narcan, along with a growing awareness of the hazards of opioid ingestion, has reduced overdose mortality. [3]

In 2017, the American Medical Association's (AMA) Opioid Task Force recommended in a guideline that physicians "...consider co-prescribing the drug(naloxone) when clinically appropriate for patients who are at risk for opioid overdose or might be in a position to help someone else at risk." [4]

In December 2018, Admiral Brett P. Giroir, the U.S. Health and Human Services (HHS) Assistant Secretary for Health, released federal guidelines related to the prescribing of naloxone to populations at high risk for opioid overdose. The act of prescribing naloxone along with opioid prescriptions is called co-prescribing. HHS guidelines recommend that clinicians co-prescribe naloxone to people on high doses of opioid medications or have other high risk factors. [5]

According to a 2020 article by Health Crisis Alert: [6]

The study, "A Way Forward: How Naloxone Saves Lives from Overdoses" published by CME Outfitters, a continuing medical education organization, suggests that co-prescribing naloxone is not only a life-saving measure for those with opioid use disorder (OUD) but a way for prescribers to talk to patients about the risk of accidental overdose.

Naloxone co-prescribing

Naloxone comes with a variety of delivery systems, including nasal spray, intravenous infusion, as well as subcutaneous and intramuscular injection (also encompassing auto-injection pens). Administering injectable naloxone does require professional training. Administering through the nasal spray, Narcan, and the auto-injectable device, Evizio, is "...easy and suitable for home use." [7] According to HHS, most health insurance plans cover at least one of these products. [8]

Federal guidelines

In 2018 a Joint Meeting of the FDA's Anesthetic and Analgesic Drug Products Advisory Committee and the Drug Safety and Risk Management Advisory Committee recommended label changes that encouraged the co-prescribing of naloxone along with opioids, making the potential life-saving opioid antagonist more available to patients and the medical community. Branded versions of naloxone include Evizo, an auto-injector and the nasal spray Narcan. Objections to the recommendation included concerns over the cost (estimated by the FDA) of the auto-injector at $4,000/dose. It was noted that the FDA's estimates were inflated. Generic naloxone lists at around $40/dose; Narcan at $125; and that the manufacturer of Evzio had announced a cheaper, generic version of the drug. [9]

U.S. federal guidelines recommend that doctors co-prescribe naloxone for all patients who are prescribed opioids and also meet at least one of the following criteria: [8]

Additionally, the prescribers are encouraged to authorize naloxone outright to patients who are not prescribed opioids if they use illegal street drugs or engage in other high-risk behavior. [8]

State laws

States have taken the lead on this issue. In Tennessee, the combination of the co-prescription of naloxone with opioid medications and telehealth access have helped the state battle its own opioid epidemic. During the 2020 coronavirus pandemic, Tennessee saw an increase in fatal opioid overdoses. The state responded by incorporating recommendations from the Commissioner's Committee on Chronic Pain Guidelines that support co-prescribing naloxone to certain high-risk populations. [1]

Many states are increasing funding to combat the opioid crisis. The state of Michigan, for example, has earmarked $80 million in grant funding for the issue. The state saw 8,000 deaths from opioid overdoses between 2015 and 2020. [10]

Vermont required co-prescribing naloxone to patients who take at least 90 MME/d or who also take benzodiazepines with opioids. In Virginia, doctors are required to co-prescribe for patients at 120 MME/d or greater or for individuals who also take benzodiazepines. [11] As a result, these two states have the highest co-prescription rates in all of the United States. [12]

In New Jersey in June 2020, the state's attorney general issued a policy that requires, for the duration of the coronavirus pandemic, prescribers to prescribe naloxone to patients who take higher doses of opioids or who take opioids with anti-anxiety benzodiazepines. The urgency of the pandemic, according to the news site North New Jersey, led the state to issue the new requirements when it did. [13]

According to the National Institute on Drug Abuse, most pharmacies across the U.S. dispense naloxone without a physician's prescription. [14] Data presented by the Prescription Drug Abuse Policy System indicates that, in 49 states (every state except Nebraska), pharmacists are allowed to dispense naloxone without a "patient-specific prescription from another medical professional." [15]

According to the U.S. Centers for Disease Control and Prevention (CDC), the number of prescriptions for naloxone doubled in just a single year (between 2017 and 2018). However, for every 70 "high-dose opioid" prescription, only one naloxone prescription is dispensed. [16]

A research project from the University of Kentucky's Institute for Pharmaceutical Outcomes and Policy at the College of Pharmacy studied the association between legally mandated naloxone co-prescription and dispensing the drug to patients across the United States. 88 prescriptions per 100,000 were distributed in Virginia; 111/100,000 were dispensed in Vermont during the first month the law was in effect. In contrast, 16 prescriptions per 100,000 were dispensed in the ten states with the country's highest overdose rates (West Virginia, New Hampshire, Ohio, Washington, DC, Massachusetts, Maryland, Rhode Island, Maine, Connecticut, and Kentucky) and six per/100,000 were distributed in the remaining 38 states. The researchers concluded that statutes requiring naloxone prescriptions for individuals at risk for opioid overdose and those people actually receiving naloxone resulted in "...further reduction of opioid-related harm." [17]

State legislation

Legislators in several U.S. states have pushed changes to state laws regarding naloxone co-prescribing. Many have passed and were signed into law. Examples include:

Special populations

Within the Indian Health Service, co-prescribing is on the rise. The Gallup Indian Medical Center, a 99-bed hospital in Gallup, New Mexico, on the border of the Navajo Reservation, [26] started co-prescribing naloxone with opioids in May 2015. [27]

Issues

Access

One contemporary issue for 2020 is addressing the opioid use disorder crisis in the midst of the coronavirus global pandemic. According to the academic journal Health Affairs , ". . . we are living in a time when only 7 percent of doctors can effectively treat opioid use disorder . . ." [28]

Forty-two percent of counties in the United States have no buprenorphine prescribers. "Access is almost non-existent," according to Health Affairs. [28]

However, some states are getting creative. In New Jersey, the state sponsored a free giveaway of naloxone without a prescription or appointment at the end of September 2020. [29]

In a 2016 article in Substance Abuse , a peer-reviewed medical journal, the authors concluded that although some medical providers have concerns about legal risks concerning co-prescribing naloxone to pain patients, "such concerns are unfounded" and that the legal risk is no higher than it is with any other medication. Most states have laws that give explicit protection from legal liability for providers who prescribe or dispense naloxone. According to the article, "Where a prescriber determines, in his or her clinical judgment, that a patient is at risk of overdose, co-prescribing naloxone is a reasonable and prudent clinical and legal decision. No clinician should fail or refuse to issue such a prescription based on liability concerns." [30]

State legislation

In 2018, only one naloxone prescription was dispensed for each 70 "high-dose" opioid prescriptions in the U.S., according to the Centers for Disease Control and Prevention. In South Carolina, a bill was introduced in the state House that would require doctors and other medical professionals who can prescribe medication to prescribe Narcan (or a naloxone generic) to patients who have ever overdosed on opioids, have a history of drug abuse, or who are being prescribed any benzodiazepines (such as Xanax) while on opioids. [31]

Currently, Americans under the age of 50 are more likely to die from a narcotic overdose than from any other cause. While many pharmacies will dispense Narcan or naloxone without a prescription, a prescription is usually required for health insurance reimbursement. [31]

Opioid co-prescribing with benzodiazepine

Between 2014 and 2016, U.S. clinicians prescribed benzodiazepines at 66 million office visits each year. In 35 percent of those cases, the patient being prescribed benzodiazepines was also currently on an opioid prescription. A Stanford University researcher said in January 2020 that benzodiazepines are "implicated in a third of opioid overdoses" because they can increase the negative effects of opioids on the respiratory system. The CDC's guidelines for opioid prescriptions for chronic pain recommends against co-prescribing both benzodiazepines and opioids together because of the high level of that risk. [32] In 2016, the Food and Drug Administration issued a black-box warning (the FDA's strongest type of warning) against co-prescribing benzodiazepines and opioids, including cough medicines containing opiates. [33] [34]

A 2019 study in PLOS Medicine (funded by the National Institute for Health Research (NIHR)) recommends that doctors avoid co-prescribing benzodiazepines to opioid dependent patients who are being treated with methadone or buprenorphine. According to a University of Bristol study, patients in that population have a "three-fold increase in risk of overdose death." According to the study, one reason doctors might be ignoring clinical guidelines against co-prescribing the two types of medication together is because many opioid dependent patients have high levels of anxiety. [35]

See also

Related Research Articles

<span class="mw-page-title-main">Naloxone</span> Opioid receptor antagonist

Naloxone, sold under the brand names Narcan among others, is a medication used to reverse or reduce the effects of opioids. It is commonly used to counter decreased breathing in opioid overdose. Effects begin within two minutes when given intravenously, and within five minutes when injected into a muscle. The medicine can also be administered by spraying it into a person's nose. Naloxone commonly blocks the effects of opioids for 30 to 90 minutes. Multiple doses may be required, as the duration of action of some opioids is greater than that of naloxone.

<span class="mw-page-title-main">Drug overdose</span> Use of an excessive amount of a drug

A drug overdose is the ingestion or application of a drug or other substance in quantities much greater than are recommended. Typically it is used for cases when a risk to health will potentially result. An overdose may result in a toxic state or death.

<span class="mw-page-title-main">Prescription drug</span> Medication legally requiring a medical prescription before it can be dispensed

A prescription drug is a pharmaceutical drug that legally requires a medical prescription to be dispensed. In contrast, over-the-counter drugs can be obtained without a prescription. The reason for this difference in substance control is the potential scope of misuse, from drug abuse to practicing medicine without a license and without sufficient education. Different jurisdictions have different definitions of what constitutes a prescription drug.

<span class="mw-page-title-main">Opioid use disorder</span> Medical condition

Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Opioid withdrawal symptoms include nausea, muscle aches, diarrhea, trouble sleeping, agitation, and a low mood. Addiction and dependence are important components of OUD.

<span class="mw-page-title-main">Buprenorphine</span> Opioid used to treat opioid use disorder

Buprenorphine is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection, as a skin patch (transdermal), or as an implant. For opioid use disorder, it is typically started when withdrawal symptoms have begun and for the first two days of treatment under direct observation of a health-care provider. In the United States, the combination formulation of buprenorphine/naloxone (Suboxone) is usually prescribed to discourage misuse by injection. Maximum pain relief is generally within an hour with effects up to 24 hours. Buprenorphine affects different types of opioid receptors in different ways. Depending on the type of receptor, it may be an agonist, partial agonist, or antagonist. In the treatment of opioid use disorder buprenorphine is an agonist/antagonist, meaning that it relieves withdrawal symptoms from other opioids and induces some euphoria, but also blocks the ability for many other opioids, including heroin, to cause an effect. Unlike full agonists like heroin or methadone, buprenorphine has a ceiling effect, such that taking more medicine will not increase the effects of the drug.

<span class="mw-page-title-main">Sufentanil</span> Chemical compound

Sufentanil, sold under the brand names Dsuvia and Sufenta, is a synthetic opioid analgesic drug approximately 5 to 10 times as potent as its parent drug, fentanyl, and 500 times as potent as morphine. Structurally, sufentanil differs from fentanyl through the addition of a methoxymethyl group on the piperidine ring, and the replacement of the phenyl ring by thiophene. Sufentanil first was synthesized at Janssen Pharmaceutica in 1974.

<span class="mw-page-title-main">Opioid overdose</span> Medical condition

An opioid overdose is toxicity due to excessive consumption of opioids, such as morphine, codeine, heroin, fentanyl, tramadol, and methadone. This preventable pathology can be fatal if it leads to respiratory depression, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils, and unconsciousness, however its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including permanent brain damage.

In the United States, prescription monitoring programs (PMPs) or prescription drug monitoring programs (PDMPs) are state-run programs which collect and distribute data about the prescription and dispensation of federally controlled substances and, depending on state requirements, other potentially abusable prescription drugs. PMPs are meant to help prevent adverse drug-related events such as opioid overdoses, drug diversion, and substance abuse by decreasing the amount and/or frequency of opioid prescribing, and by identifying those patients who are obtaining prescriptions from multiple providers or those physicians overprescribing opioids.

<span class="mw-page-title-main">Buprenorphine/naloxone</span> Opioid treatment

Buprenorphine/naloxone, sold under the brand name Suboxone among others, is a fixed-dose combination medication that includes buprenorphine and naloxone. It is used to treat opioid use disorder, and reduces the mortality of opioid use disorder by 50%. It relieves cravings to use and withdrawal symptoms. Buprenorphine/­naloxone is available for use in two different forms, under the tongue or in the cheek.

The Pennsylvania Department of Drug and Alcohol Programs is a cabinet-level agency in the Government of Pennsylvania under Governor Tom Wolf. The objective of this department is to manage and distribute state and federal funds used to oversee alcohol and drug prevention, intervention and treatment services.

The California State Legislature passed an act to amend Section 1714.22 of the Civil Code, relating to drug overdose treatment in 2014. California Assembly Bill 1535 (2014) delegated the authority to all properly licensed California state pharmacists who had undergone a training program of at least one hour of continuing education about the pharmacology of naloxone hydrochloride to dispense naloxone under standards developed by the Medical Board of California in conjunction with the California Society of Addiction Medicine, the California Pharmacists Association, and any other appropriate entities.

<span class="mw-page-title-main">Opioid epidemic in the United States</span> Ongoing overuse of opioid medication in the US

In the United States, the opioid epidemic is an extensive ongoing overuse of opioid medications, both from medical prescriptions and from illegal sources. The epidemic began in the United States in the late 1990s, according to the Centers for Disease Control and Prevention (CDC), when opioids were increasingly prescribed for pain management and resulted in a rise in overall opioid use throughout subsequent years. The great majority of Americans who use prescription opioids do not believe that they are misusing them.

<span class="mw-page-title-main">Opioid epidemic</span> Deaths due to abuse of opioid drugs

The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse/abuse, and overdose deaths attributed either in part or in whole to the class of drugs opiates/opioids since the 1990s. It includes the significant medical, social, psychological, and economic consequences of the medical, non-medical, and recreational abuse of these medications.

The New Jersey “Opioid Antidote Prescription” bill is legislation sponsored in the New Jersey State Senate. The bill, numbered NJ S. 2323, requires a co-prescription of an opioid overdose agent, such as naloxone, with prescriptions for opioid medications for patients who have a high risk of overdosing and tightens restrictions on the dispensing of opioid medications in New Jersey.

The Illinois “Opioids-Covid-19-Naloxone” Resolution is legislation sponsored in the Illinois State Senate. The bill, numbered IL SR 1184, prompts the state of Illinois to examine the rise in opioid overdoses due to the COVID-19 pandemic. The bill also urges the state to improve and increase access to naloxone, an opioid overdose reversal drug.

The New York mandatory opioid antagonist prescription bill is legislation sponsored in the New York State Senate and Assembly. The Senate bill, numbered NY S. 5150-B, sponsored by state Senator Pete Harckham, will require prescribers to co-prescribe an opioid antagonist with the first opioid prescription of the year for certain high-risk patients to combat accidental overdoses.

The South Carolina opioid overdose prevention bill is legislation sponsored in the South Carolina state legislature. The bill, numbered SC H.B. 4711 and sponsored by state Representative Russell Fry, would require prescribers to offer a prescription for naloxone to patients at high risk of an opioid overdose.

The California naloxone requirement bill is legislation passed by the California legislature and signed into law in 2018. The bill, numbered AB 2760, and sponsored by state Assembly member Jim Wood, requires medical prescribers to offer a prescription for naloxone to certain populations at higher risk of overdosing from opiate drugs.

Over a period of six months, Colorado legislation HB 20–1065, the Colorado Harm Reduction Substance Use Disorders Law, passed through both houses of the state legislature with bipartisan sponsorship and was signed into law by Governor Jared Polis (D). The law provides support mechanisms and medications to individuals with substance abuse disorder. It also provides protection to pharmacists and ordinary Good Samaritans who are attempting to assist those with the potential of drug overdose and its subsequent consequences.

<span class="mw-page-title-main">Prescription drug addiction</span> Medical condition

Prescription drug addiction is the chronic, repeated use of a prescription drug in ways other than prescribed for, including using someone else’s prescription. A prescription drug is a pharmaceutical drug that may not be dispensed without a legal medical prescription. Drugs in this category are supervised due to their potential for misuse and Substance use disorder. The classes of medications most commonly abused are opioids, central nervous system (CNS) depressants and central nervous stimulants. In particular, prescription opioid is most commonly abused in the form of prescription analgesics.

References

  1. 1 2 "Co-prescribing naloxone helps Tennessee combat increased opioid abuse during pandemic". Health Crisis Alert. 2020-07-08. Retrieved 2020-07-28.
  2. ↑ Carey, Liz (2020-10-22). "PEW researchers: expanded naloxone access can curb opioid deaths". Homeland Preparedness News. Archived from the original on 2020-11-01. Retrieved 2020-10-29.
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  6. ↑ "Study recommends clinicians co-prescribe naloxone to reduce opioid deaths". Health Crisis Alert. 2020-07-07. Retrieved 2020-07-28.
  7. ↑ Abuse, National Institute on Drug (2020-02-20). "Opioid Overdose Reversal with Naloxone (Narcan, Evzio)". www.drugabuse.gov. Retrieved 2020-02-24.
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  9. ↑ "FDA Recommends Co-Prescribing Naloxone with Opioids". Practical Pain Management. Montclair NJ: Remedy Health Media. 3 January 2019.
  10. ↑ Drew, Trevor (2020-09-28). "Michigan announces $80 million for opioids crisis response". WPBN. Retrieved 2020-10-01.
  11. ↑ Jones, Christopher M.; Compton, Wilson; Vythilingam, Meena; Giroir, Brett (2019-08-06). "Naloxone Co-prescribing to Patients Receiving Prescription Opioids in the Medicare Part D Program, United States, 2016-2017". JAMA. 322 (5): 462–464. doi:10.1001/jama.2019.7988. ISSN   0098-7484. PMC   6686765 . PMID   31386124.
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  18. ↑ "Bill Text - AB-2760 Prescription drugs: prescribers: naloxone hydrochloride and other FDA-approved drugs". leginfo.legislature.ca.gov. Retrieved 2020-07-22.
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  21. ↑ "Illinois General Assembly - Bill Status for SR1184". www.ilga.gov. Retrieved 2020-06-14.
  22. ↑ "Illinois General Assembly - Full Text of SR1184". www.ilga.gov. Retrieved 2020-06-14.
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  24. ↑ "State of New York S5150B 2019-2020 Regular Sessions in Senate" (PDF). 2019-04-11. Archived from the original on 2022-05-21. Retrieved 2022-11-13.
  25. ↑ "2019-2020 Bill 4711 Text of Previous Version (Feb. 20, 2020) - South Carolina Legislature Online". www.scstatehouse.gov. Retrieved 2020-07-09.
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  31. 1 2 Patel, Anjali (2020-01-21). "SC lawmaker looks to increase access to life-saving drugs to those at risk of overdosing". WPDE. Retrieved 2020-02-24.
  32. ↑ "Opioid-Benzo Co-Prescribing Continues, Despite Risks". www.medpagetoday.com. 2020-01-21. Retrieved 2020-02-24.
  33. ↑ Span, Paula (2018-03-16). "A Quiet Drug Problem Among the Elderly". The New York Times. ISSN   0362-4331 . Retrieved 2020-02-24.
  34. ↑ "FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use". FDA. 2020-02-20. Archived from the original on 2019-09-14. Retrieved 2020-02-24.
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