BETHESDA, MD—Neurologists are increasingly providing naloxone as a risk mitigation strategy to patients taking opioids for chronic pain. Naloxone has successfully reduced the risk of overdose among users of illicit drugs for approximately 20 years.
Prescribing naloxone for patients who take opioids for chronic pain to reduce overdoses and mortality is not yet common practice, but this strategy “has a unique and compelling rationale, is expanding around the country, and may be important to have in place prior to interventions restricting access to opioids,” said Phillip Coffin, MD, Director of Substance Use Research in the HIV Prevention Section at the San Francisco Department of Public Health. Dr. Coffin spoke about the effectiveness of risk mitigation strategies for opioid treatment at a workshop organized by the National Institutes of Health.
Phillip Coffin, MD
Preliminary results of a 2014 survey showed that this practice is carried out in at least 16 states. In San Francisco, providing a prescription for take-home naloxone is now recommended for all patients taking opioids for chronic pain at public health primary care clinics, said Dr. Coffin. The program has been well received by primary care providers, based on early survey results, he added.
In addition to the San Francisco Health Network, sites that provide naloxone to patients receiving chronic opioids for pain include the US Department of Veterans Affairs, where the strategy is widely implemented; the US Army base in Fort Bragg, North Carolina; and the Denver Health Medical Center.
Data on Naloxone in Patients Taking Opioids Are Limited
The effectiveness of take-home naloxone in heroin users is well established and “is one of the few interventions with data that suggest a direct impact on opioid overdose mortality,” said Dr. Coffin, citing the significant decrease in the number of heroin-related deaths in San Francisco and other cities after the distribution of naloxone to heroin users.
As is the case with other strategies to reduce risk in patients on chronic opioid therapy, data on the effectiveness of the naloxone strategy are limited, noted Dr. Coffin. In San Francisco, he and his colleagues are conducting a study called the Naloxone Prescription for Opioid Safety Evaluation that is evaluating the effect of providing take-home naloxone to patients receiving chronic opioid therapy at six San Francisco Department of Public Health primary care clinics.
Although randomized controlled trials evaluating this intervention would be ideal, there is a “compelling rationale” for using this approach in this population, and “it’s hard to argue against it logically,” said Dr. Coffin. No randomized trial data are available regarding the use of epinephrine pens for anaphylaxis, although this strategy is widespread as a preventive measure, he pointed out.
The increase in opioid prescribing for pain has been accompanied by an increase in prescription opioid overdose deaths in San Francisco, where more than 90% of the deaths from opioid overdoses are caused by opioid analgesics, said Dr. Coffin.
An Opportunity to Discuss Opioid Safety
The decision to offer naloxone to all primary care patients receiving chronic opioid treatment in the San Francisco Health Network simplifies clinical practice and introduces the principle of prescribing naloxone for “risky drugs, not risky patients,” he explained. He noted that it is difficult to assess an individual’s risk of an overdose accurately when he or she is starting treatment. This strategy also “reduces the cognitive dissonance among providers, who might think, ‘I’m not going to prescribe naloxone because that means I think the person is at risk of an overdose,’” he added.
The language of the protocol has been adjusted to avoid the term “overdose” and refer instead to “opioid safety” because patients on prescription opioids do not perceive themselves as being at risk for an overdose, said Dr. Coffin.
In the San Francisco program to date, take-home naloxone has been prescribed to more than 600 patients taking opioids for pain. Data from a survey of 105 providers at clinics offering naloxone to these patients revealed that 77% of providers had prescribed naloxone to at least one patient, and 98% said that they likely would prescribe it again. In addition, 75% of providers said that prescribing naloxone helped them communicate information about opioids with the patient, and 75% said it helped open a discussion about the alternatives to opioids for pain. No providers said that they thought that prescribing naloxone had a negative effect on their relationship with their patients, said Dr. Coffin.
Examples of specific clinician responses provided in the survey included the following statement: “The act of prescribing naloxone has made clear to my patients that I am concerned about the risk of overdose, and it has also shown them that I care.” Another physician commented, “The ability to prescribe naloxone has been the most positive change to our management of chronic pain.”