Co-prescribing naloxone with opioids

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
Main article: Naloxone

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]

  • Receive 50 or more morphine milligram equivalents per day (MME/d)
  • Have a respiratory condition (for example, COPD or sleep apnea)
  • Are prescribed benzodiazepine drugs
  • Have a substance abuse disorder for substances other than opioids
  • Drink heavily
  • Have a mental health disorder

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:

  • California. Signed into law in 2018, the California Naloxone Requirement Bill requires medical prescribers to offer a prescription for naloxone (or equivalent) to certain populations at higher risk of overdosing from opiate drugs.[18]
  • Colorado. The Colorado Harm Reduction Substance Use Disorders Law requires that the cost of opioid antagonists such as Narcan and Evzio be covered by health insurance.[19][20]
  • Illinois. The Illinois Opioids-Covid-19-Naloxone Resolution, a legislative bill that is still working its way through the Illinois State Senate,[21] if passed would urge the state to study the increase in opiate overdose deaths in Illinois and would urge the state to propose changes to prescription rules to include co-prescription of naloxone to patients in high-risk groups of overdose.[22]
  • New Jersey. Still pending in the state Senate, the New Jersey Opioid Antidote Prescription Bill would require a co-prescription of naloxone or other opioid overdose agent with prescriptions for opioid medications for all patients who have a high risk of overdosing and tightens restrictions on the dispensing of opioid medications within the state.[23] Note that this is a distinction from other bills, which would merely allow or suggest co-prescription; in this bill, it would be required.
  • New York. A bill introduced in New York, the New York Mandatory Opioid Antagonist Prescription Bill, would require doctors and other prescribers to co-prescribe an opioid antagonist agent with the first opioid prescription of the year for certain high-risk patients.[24]
  • South Carolina. The South Carolina Opioid Overdose Prevention Bill if passed would require prescribers to offer a prescription for naloxone (or other equivalent opioid overdose medication) to patients at high risk of an opioid overdose. Note that this bill is distinctively different than the others; it merely requires the prescriber to "offer" the prescription rather than require the prescription to be issued.[25]

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

References
  1. "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.
  3. Srivastava, A. Benjamin; Gold, Mark S. (2018-03-01). "Beyond Supply: How We Must Tackle the Opioid Epidemic". Mayo Clinic Proceedings. 93 (3): 269–272. doi:10.1016/j.mayocp.2018.01.018. PMID 29502558.
  4. "New guidance: Who can benefit from naloxone co-prescribing". American Medical Association. Retrieved 2020-02-24.
  5. Affairs (ASPA), Assistant Secretary for Public (2018-12-19). "HHS recommends prescribing or co-prescribing naloxone to patients at high risk for an opioid overdose". HHS.gov. Retrieved 2020-02-24.
  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.
  8. "Naloxone: The Opioid Reversal Drug that Saves Lives" (PDF). U.S. Department of Health and Human Services. Archived (PDF) from the original on 2018-12-19. Retrieved 2020-02-24.
  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.
  12. Abuse, National Institute on Drug (2019-08-06). "Co-prescribing naloxone in Medicare Part D increases". www.drugabuse.gov. Retrieved 2020-02-24.
  13. Janoski, Steve. "New Jersey says doctors must prescribe Narcan alongside opioids for at-risk patients". North Jersey. Retrieved 2020-06-03.
  14. "Opioid Overdose Reversal with Naloxone (Narcan, Evzio)". www.drugabuse.gov. 2020-02-20. Archived from the original on 2017-04-23. Retrieved 2020-02-24.
  15. "PDAPS - Naloxone Overdose Prevention Laws". www.pdaps.org. Retrieved 2020-02-24.
  16. "Naloxone saves lives". Centers for Disease Control and Prevention. 2019-08-06. Archived from the original on 2019-08-06. Retrieved 2020-02-24.
  17. Sohn, Minji; Talbott, Jeffrey (21 June 2019). "Association of Naloxone Coprescription Laws With Naloxone Prescription Dispensing in the United States". JAMA Network Open. American Medical Association. 2 (6): e196215. doi:10.1001/jamanetworkopen.2019.6215. PMC 6593960. PMID 31225895.
  18. "Bill Text - AB-2760 Prescription drugs: prescribers: naloxone hydrochloride and other FDA-approved drugs". leginfo.legislature.ca.gov. Retrieved 2020-07-22.
  19. Severance, Ryan. "Colorado bills addressing opioid crisis signed into law". The Pueblo Chieftain. Retrieved 2020-09-02.
  20. "Harm Reduction Substance Use Disorders | Colorado General Assembly". leg.colorado.gov. Retrieved 2020-09-02.
  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.
  23. "Archived copy" (PDF). Archived from the original (PDF) on 2020-06-14. Retrieved 2020-04-22.{{cite web}}: CS1 maint: archived copy as title (link)
  24. https://legislation.nysenate.gov/pdf/bills/2019/S5150B
  25. "2019-2020 Bill 4711 Text of Previous Version (Feb. 20, 2020) - South Carolina Legislature Online". www.scstatehouse.gov. Retrieved 2020-07-09.
  26. "Gallup Indian Medical Center". Indian Health Service. Archived from the original on 2015-05-20. Retrieved 2020-02-24.
  27. Dunton, Catherine (2019-07-12). "Co-prescribing Naloxone with Opioids May Help Curb the Devastating Risks of Opioid Misuse". Indian Health Service. Retrieved 2020-02-24.{{cite news}}: CS1 maint: url-status (link)
  28. Kang, Navdeep S. (2020). "Once The Coronavirus Pandemic Subsides, The Opioid Epidemic Will Rage | Health Affairs". Health Affairs Forefront. doi:10.1377/forefront.20200407.290720.
  29. "Department of Human Services | stopoverdoses". nj.gov. Retrieved 2020-10-01.
  30. Davis, Corey S.; Burris, Scott; Beletsky, Leo; Binswanger, Ingrid (2016-10-01). "Co-prescribing naloxone does not increase liability risk". Substance Abuse. 37 (4): 498–500. doi:10.1080/08897077.2016.1238431. ISSN 0889-7077. PMC 5567808. PMID 27648764.
  31. 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.
  35. Macleod, John; Steer, Colin; Tilling, Kate; Cornish, Rosie; Marsden, John; Millar, Tim; Strang, John; Hickman, Matthew (2019-11-26). Tsai, Alexander C. (ed.). "Prescription of benzodiazepines, z-drugs, and gabapentinoids and mortality risk in people receiving opioid agonist treatment: Observational study based on the UK Clinical Practice Research Datalink and Office for National Statistics death records". PLOS Medicine. 16 (11): e1002965. doi:10.1371/journal.pmed.1002965. ISSN 1549-1676. PMC 6879111. PMID 31770388.
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