Increasing Naloxone Access and Use to Prevent Opioid Overdose Death and Disability

Abstract

In 2018, the Surgeon General released a public health advisory emphasizing the importance of naloxone in preventing opioid overdose deaths. Legislation is rapidly changing to simplify the process of obtaining naloxone by expanding who can receive and distribute the life-saving drug. Even with legislation in place expanding access to naloxone, the drug is underutilized and health care providers are responsible for ensuring these efforts are put to use within their practice. Legislative changes will be summarized and the role of the health care provider will be discussed.

“When given in time, naloxone can expand the window of opportunity for intervention by emergency responders. Naloxone can save lives.”

Prescription drug abuse has reached epidemic proportions in the United States. It is estimated that 1.9 million Americans abuse or are dependent on opioid analgesics and that the rate of opioid-related overdose mortalities nearly quadrupled since 1999.^1,2 In 2015 alone, 33 000 lives were lost to opioid overdose. ³ In April 2018, the Surgeon General released a public health advisory, for the first time in over a decade, explaining the importance of naloxone and emphasizing the need for greater awareness and use of this life-saving drug. ⁴

Naloxone is an opioid antagonist that can temporarily reverse the respiratory depression associated with opioid overdose. When given in time, naloxone can expand the window of opportunity for intervention by emergency responders. Naloxone can save lives. However, naloxone is not always readily available when and where it is needed. Increasing naloxone access and use is one strategy for preventing opioid overdose death and disability. Legislative changes that expand naloxone access and the role of the health care practitioner are described below.

Legislative Changes to Improve Naloxone Access

All 50 states allow medical providers to prescribe naloxone to patients at risk for opioid overdose. ⁵ However, this traditional process of prescribing and dispensing has been unable to meet the needs of the growing opioid crisis. There are a number of reasons this traditional model of prescription fails. For example, not all individuals at risk of overdose have a primary care provider they see regularly. Lack of insurance and transportation frequently serve as barriers to an office visit or trip to the pharmacy. And even those patients with established primary care providers and resources to acquire the medication may not discuss or request naloxone due to the stigma of addiction or fear of legal repercussions.

Legislative changes to increase access to naloxone vary by state but generally expand access through one of three strategies ⁶ :

1. Expanding who can receive naloxone

2. Simplifying the process of obtaining naloxone

3. Expanding who can distribute naloxone

Expanding Who Can Receive Naloxone

As described above, many patients at risk for opioid overdose lack the resources or comfort level to seek and fill naloxone prescriptions. To ameliorate this, many states now allow third-party prescriptions or prescriptions issued to an individual who is not personally at risk of overdose for the purpose of use on someone else. This prescription model allows family members or friends to seek naloxone from their provider without the stigma associated with a personal need. Family and friends are an extremely important target for naloxone as 77% of opioid overdoses take place outside a medical setting, over half occurring in the home. ⁷ Importantly, nearly all states also provide “Good Samaritan” legal protection for these laypersons to distribute, carry, and/or administer naloxone if the need arises. ⁶

Simplifying the Process of Obtaining Naloxone

Removing the need to go to the doctor simplifies the process of obtaining naloxone. Many states attempt to streamline this process through the use of non–patient-specific prescriptions. As of January 2018, 49 states and the District of Columbia permit some form of non–patient-specific prescription for naloxone. ⁶ A variety of non–patient-specific prescription models exist. Standing orders and collaborative practice agreements, authorized by licensed prescribers, allow pharmacies to dispense naloxone to patients without a prescription. Protocol orders also allow pharmacies to dispense naloxone; however, the authorization comes from the state board of health or pharmacy licensing board rather than a prescriber. A handful of states grant pharmacists prescriptive authority without an order or agreement with a licensed provider, board of pharmacy or board of health.

Expanding Who Can Distribute Naloxone

Traditional prescription models limit who can distribute medications. Most frequently, pharmacists serve as drug distributors. However, naloxone distribution via standing order at the pharmacy setting is just gaining traction and not well known to the public, especially those at greatest need for naloxone. Several states have laws in place that allow non–health care professionals to distribute naloxone. Most commonly, this takes place in Overdose Education and Naloxone Distribution (OEND) programs. OEND programs exist to educate lay persons or first responders (including police or firefighters) on identifying and responding to opioid overdose. These programs operate in various venues with high access to opioid users and their family members and friends (needle-syringe access programs, inpatient/outpatient treatment centers, support groups, etc).

Role of the Health Care Practitioner

Even with legislation in place expanding access to naloxone, the life-saving antidote is underutilized. A recent study in the American Journal of Emergency Medicine found that some opioid users are more likely than others to know about and use naloxone. ⁸ Patients presenting to the emergency department (for any reason) identified as opioid users were administered a 14-question survey about their opioid use and awareness, access to and use of naloxone. The study found that naloxone awareness and access was greater among patients with a history of injecting heroin. Specifically, 76% of injectable heroin users reported having heard of naloxone and 39% reported having access to naloxone while just 32% of those with no history of injecting heroin had heard of naloxone and only 2% reported having access to it.

These findings are concerning and suggest that current naloxone education and distribution efforts may not be reaching all types of opioid users. It is imperative that all health care providers are screening patients for factors that increase risk for opioid overdose. The Surgeon General lists the following criteria for elevated risk of opioid overdose ⁴ :

• Prescription opioid misuse or use of heroin or illicit synthetic opioids

• Having an opioid use disorder

• Recent discharge from emergency medical care following an opioid overdose

• Recently released from incarceration with a history of opioid misuse or opioid use disorder

• Use of opioids for long-term management of chronic pain, especially at high doses or when used in combination with alcohol or other sedating medications

In the primary care setting, patients at risk for opioid overdose should receive counseling on the use of naloxone and should be provided a prescription for naloxone. Patients should also be encouraged to discuss the use of naloxone with their family members and friends and ensure these individuals are trained in identifying overdose symptoms and administering the medication, if necessary.

Prescribers should find out whether their state permits pharmacists to prescribe or dispense naloxone under a standing order or collaborative practice agreement and engage pharmacy partners to ensure greater community access to naloxone.

In the pharmacy setting, pharmacists should partner with prescribers to establish standing orders or collaborative practice agreements to ensure the ability to legally dispense naloxone to the public. Pharmacists should strive to make naloxone distribution without the need for a prescription standard practice, especially in rural areas where access to other providers and programming is limited. Naloxone should be prominently displayed behind the counter (similar to pseudoephedrine products currently) and naloxone availability should be marketed at the pharmacy so customers are aware of the ability and process to obtain it.

Pharmacists should ensure all patients who receive a naloxone prescription are trained in administering the medication and encourage the patient to refer family members and friends to the pharmacy for demonstration and training as well.

Health care providers should be aware of and advocate for legislation that expands access to naloxone in their state. Providers are also responsible for ensuring these legislative efforts are put to use within their practice.