WASHINGTON – More than 20 patients recently were admitted into New Haven, Conn., hospitals for overdoses of fentanyl on the same night – and many of them required multiple naloxone injections to stabilize, according to Margaret H. Chaplin, MD.
“We’re still going to lose people, but naloxone is obviously very important,” Dr. Chaplin, a psychiatrist who serves as program director of Community Mental Health Affiliates in New Britain, Conn., said during a presentation at the American Psychiatric Association’s Institute on Psychiatric Services.
Dr. Margaret H. Chaplin
The two ways it is most commonly prescribed, Dr. Chaplin said, is either to write a standing order for the drug to be shipped to the practice from the manufacturer, which is what community mental health and addiction service providers tend to do, or to write the prescription as needed when seeing patients. The former scenario means patients who are in the midst of an overdose do not need to wait for emergency personnel to arrive on the scene, Dr. Chaplin said.
There are three formulations: a nasal application, an intramuscular auto-injector version, and a syringe application; Dr. Chaplin said the nasal formulation is easier to store and to administer. The nasal version comes in a two-pack of 4 mg/0.1 mL doses, and the manufacturer also offers an app that gives video instructions for how to administer it.
“It’s incredibly easy to use. You stick it in a person’s nose and push,” Dr. Chaplin said. Do not prime the dose first, however. “If you do, you’ve lost the dose. Don’t push [the applicator] until it is in the nose.”
The auto-injectable formulation (Evzio) comes in a 0.4mg/0.4mL dose and is packaged with clear voice instructions recorded in the device.
Generic versions of naloxone are available. However, Dr. Chaplin said the branded versions are far easier to prescribe and administer because generics need additional scripts for the applicator. Until recently, the prices of generics and brand names were relatively similar. The auto-injectable version recently spiked considerably in price, Dr. Chaplin said.
Think of naloxone for people abusing opioids in the way that epinephrine for people susceptible to anaphylactic shock can save lives, Dr. Chaplin said. “Naloxone should be widely prescribed. There is no harm in administering it to a person who doesn’t need it.”
Naloxone really is effective only if it is administered at the time of the overdose, and it does not necessarily counteract the entire effect of the opioids. Therefore, people at risk of overdosing should have naloxone with them at all times, and 911 should be called at the time of naloxone’s administration.
“I always tell my patients that it will precipitate withdrawal, because I don’t want them to think of this as just a ‘morning after’ pill,” Dr. Chaplin said. Because most people with opioid addiction “fear withdrawal more than anything,” she said that usually helps prevent her patients from seeing naloxone as a tool to keep using opioids.
All people with a history of opioid overdose, anyone currently taking high doses of opioids, and anyone who has been coprescribed opioids with benzodiazepines also should be coprescribed naloxone, Dr. Chaplin said.
One dose of naloxone is not a 100% guarantee that a person will rebound from an overdose, Dr. Chaplin warned. Opioid overuse is evolving, particularly as the dangers posed by powerful street drugs, such as fentanyl and carfentanil, emerge.
Dr. Chaplin did not disclose any relevant financial information.
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