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Naloxone: Prescribing Like a Life Depends on It

Posted By Ryan Jackman, Tuesday, September 20, 2016

 

I first met Nick (name changed) in May of 2016 in a rural Emergency Department in Western Colorado as I placed a central line into his neck after he had been intubated. Nick, like far too many others, had overdosed on opioids. It was three days until Nick was extubated because of aspiration pneumonia sustained during the episode, and it was three days until I got the entire story – a story that unfortunately is not unique.

 

Nick had been working on sobriety from prescription opioids and heroin on his own, and had managed to endure withdrawal and cravings for three weeks before a relapse. When he relapsed he returned to taking the same dose of heroin he had previously used. Without the tolerance he had previously developed, his brain was overwhelmed by the heroin and his respiratory drive was compromised to the point that when his aunt found him the next morning and called 911 he was blue, unresponsive, and cold.


Drug overdose is the leading cause of accidental death in the US (having surpassed motor vehicle crashes and firearm related death in 20081,2), with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.3 Even more alarming are the number of non-fatal overdoses, estimated to be 25-30 times greater. These astonishing numbers have led the CDC and Obama Administration to name the current opioid crisis an epidemic and one of the top four epidemics currently facing the U.S. including obesity, heart disease, and cancer.4,5

 

In addition, these numbers have attracted record media attention with numerous research studies, news stories, and television documentaries all seeking to quantify and characterize the problem; something that Scott Pelley’s recent 60 Minutes monologue summarized well: "After 40 years and a trillion dollars, the nation has little to show for its war on drugs. Prisons are beyond crowded and there’s a new outbreak in the heroin epidemic. If it’s time for a change, it would be now.”6

 

One way that this change has come is in the form of naloxone, or Narcan®. It is a medication that is well known in the field of medicine, but until relatively recently was not endorsed to be prescribed to the general public; a fact that research is now showing was a fatal mistake. 7,8,9,10,11


Opioids do their most damage during an overdose by decreasing a person’s respiratory rate, which can ultimately produce coma, heart failure, and death from lack of available oxygen. Thus, reversing opioid effects in a timely manner is crucial when an overdose occurs. So crucial, that waiting for EMS to arrive and administer naloxone may be too long. For this reason, a national effort is being made to increase outpatient naloxone prescribing and training.12

 

At the Center for Dependency, Addiction, and Rehabilitation (CeDAR) in Denver, Colorado, where I work, specific attention is being given to train patients with opioid use disorder and their loved ones on the use of naloxone.13 This training consists of: Didactics on recognizing overdose vs overmedication, the value of naloxone in an overdose, assessing breathing and how to deliver rescue breaths if needed, administering intranasal naloxone, and involvement of emergency services.

 

Beginning in 2014 CeDAR began training these individuals in the inpatient rehab setting, and has received significant positive feedback from patients, family members, and friends as well as a report of an overdose reversal. Given the success of this program it was quickly expanded to the outpatient setting where it was implemented in an opioid support clinic that has been embedded into a local patient-centered medical home family medicine clinic, complete with integrated mental health services.

 

 Reversing opioid effects in a timely manner is crucial

 

This setting, with all of its services and team-based integrated care has not only allowed for this program’s streamline implementation but has also allowed for the program to be improved upon. Some of the ways in which this program was improved upon and patient care was expanded through an integrated care model include:

 

· The flexibility of performing training in both individual and group settings.

· Recognizing that naloxone training naturally provides multiple intervention/discussion points that are benefited by integrated behavioral health co-visits where the team is able to point out that:

o Naloxone offers patients and loved ones, who often feel powerless, a tool and sense of empowerment in addressing a disease that impacts every component of their lives. Additionally, it empowers the patient to treat an overdose in another person if needed.

o Addiction is a chronic disease with a relapsing-remitting pattern, and prescribing naloxone is evidence of the patient’s commitment to treatment rather than providing a patient permission to relapse.

o A naloxone prescription further invests the patient and his/her support team in his/her care

o Multiple team members available to contribute and lead training which allowed for efficiency, including working with pharmacies to have naloxone prescription available to distribute at the training.

o Continuity and breadth of care which help to increase patient and his/her support team’s buy in.

o Advocacy by members of the team for patients and within the medical community, helping to address misperceptions by other health care providers regarding naloxone and addiction.


The bottom line is that opioids are killing people and destroying social constructs, such as family, that are crucial for health. Naloxone is a tool that has been under-utilized, but that integrated health care is in the perfect position to effectively utilize and increase the number of lives that are saved. Naloxone isn’t the "silver bullet” to the opioid crisis, but like epinephrine in anaphylaxis; naloxone is the life-saving "second chance” that patients like Nick need.

 

Imagine a scenario where Nick’s aunt had naloxone on hand for immediate treatment and knew the symptoms of overdose to look for. He may not have required the same level and duration of care, and even if he had, the sense of purpose his aunt would have experienced in the moment would be much preferred to the sense of utter helplessness she experienced instead. When I met with Nick before he left the hospital for a rehab intake appointment, a prescription for naloxone in his hand, he said "Thank you. That was eye-opening. I’m glad I got to wake up.”

 

For additional clinical guidance the following online resources are available:

· Prescribetoprevent.org

· SAMHSA Opioid Overdose Toolkit: https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf

 

References

1. U.S. Department of Justice Drug Enforcement Administration. (2015). National Drug Threat Assessment Summary (DEA-DCT-DIR-008-16). https://www.dea.gov/docs/2015%20NDTA%20Report.pdf

2. Rudd, R., Aleshire, N.,Zibbell, J., Gladden, RM. (2016). Increases in Drug and Opioid Overdose Deaths — United States 2000–2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm

3. Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. (2015). Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Atlanta, GA: Center for Disease Control and Prevention. http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000- 2014.pdf.

4. Center for Disease Control and Prevention. (2016). Injury Prevention and Control: Opioid Overdose. http://www.cdc.gov/drugoverdose/epidemic/

5. The White House, Office of the Press Secretary. (2016). Fact Sheet: Obama Administration Announces Additional Actions to Address the Prescription Opioid Abuse and Heroin Epidemic [Press release]. https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-address

6. Pelley, S. (2016, June 5). A new direction on drugs. [Television broadcast]. Fager, J. (Producers), 60 Minutes. New York, CBS Broadcasting. http://www.cbsnews.com/videos/a-new-direction-on-drugs-2/

7. Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S. (2006). Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. Journal of Addictive Diseases, 25(3), 89–96.

8. Piper, T., Rudenstine, S., Stancliff, S., Sherman, S., Nandi, V., Clear, A., Galea, S. (2007). Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City. Harm. Reduct. J., 4,3.

9. Seal, K., Thawley, R., Gee, L., Bamberger,J., Kral, A., Ciccarone, D., Downing, M., Edlin, B. (2005) Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. Journal of Urban Health, 82(2), 303-311.

10. Sporer, K., Kral, A. (2007). Prescription naloxone: A novel approach to heroin overdose prevention. Annals of Emergency Medicine, 49(2), 172-177.

11. Tobin, K., Sherman, S., Beilenson, P., Welsh, C., Latkin, C. (2009). Evaluation of Staying Alive programme: Training injection drug users to properly administer naloxone and save lives. International Jouranl of Drug Policy 20:131-136

12. Dowell, D., Haegerich, TM., Chou R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep; 65:1–49

13. Pade, P., Fehling, P., Collins, S., Martin, L. (2016). Opioid Overdose Prevention in a Residential Care Setting: Naloxone Education and Distribution. Subst Abus; 0:0, 1-5. Apr 19:0 [Epub ahead of publishing]



Ryan Jackman, MD is a board certified family physician that is currently completing a one-year addiction medicine fellowship at the University of Colorado, Denver. He recently completed his family medicine residency in Grand Junction, CO. In addition to addiction medicine, his clinical interests include full spectrum medicine, obstetrics, rural medicine, and clinical-based research which currently includes a joint project for STFM-NIDA focused on expanding addiction medicine curriculum in family medicine residencies. He is married with two little girls.

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Randall Reitz says...
Posted Wednesday, September 21, 2016
Thanks for sharing these great insights, Ryan. I endorse efforts to move treatment of addictions out of the realms of moralism and criminal justice and into the realms of pragmatism and harm reduction.
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