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Patient Information: Patients and their caregivers should be
educated on how to properly identify an opioid overdose and how
to administer naloxone. Informational handouts are available for
patients and their family members (see reference #19). Patients and
caregivers should also be advised to call 911 with any administration
of naloxone (19). Naloxone should not be administered to patients
who are imminently dying. This recommendation needs to be clearly
communicated to caregivers of patients to avoid inappropriate
use. The adverse effects of naloxone administration are primarily
opioid-withdrawal related, however, precipitation of a pain crisis is
of serious concern (20). Another concern is the relatively high and
raising price of naloxone. As of 2016, estimated costs were $150 for
two nasal-spray doses (21).

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Gaps in Knowledge: The risks, benefits, safety, and best practices
of co-prescribing in the palliative care setting, especially among
patients with advanced illness and chronic cancer pain, have not
been closely examined and require further research.
References:
1. "Injury Prevention & Control: Opioid Overdose," Centers for Disease Control and
Prevention, last updated March 16, 2016, http://www.cdc.gov/drugoverdose/index.html.
2. Bruera E, Paice JA. Cancer pain management: safe and effective use of opioids. Am Soc
Clin Oncol Educ Book. 2015;35:e593-9. doi:10.14694/EdBook_AM.2015.35.e593.
3. Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing
patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-1321.
doi:10.1001/jama.2011.370.
4. Chwistek M, Ewerth N. Opioids and Chronic Pain in Cancer Survivors : Evolving
Practice for Palliative Care Clinics. J Palliat Med. 2016;19(3):19111. doi:10.1089/
jpm.2015.0471.

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5. Tan PD, Barclay JS, Blackhall LJ. Do Palliative Care Clinics Screen for Substance
Abuse and Diversion? Results of a National Survey. J Palliat Med. 2015;18(9):752-757.
doi:10.1089/jpm.2015.0098.
6. Mueller SR, et al. A Review of Opioid Overdose Prevention and Naloxone Prescribing:
Implications for Translating Community Programming Into Clinical Practice. Substance
Abuse 2016; 36(2):240-253.
7. Community-based opioid overdose prevention programs providing naloxone-United
States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:101-105
8. Oliva EM, Nevedal A, Lewis ET, et al. Patient perspectives on an opioid overdose
education and naloxone distribution program in the U.S. Department of Veterans Affairs.
Subst Abus. 2016;37(1):118-126.

19. Substance Abuse and Mental Health Services Administration - Opioid Overdose
Toolkit.https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.
pdf Accessed November 13, 2016
20. Buajordet I, Naess AC, Jacobsen D, Brors O. Adverse events after naloxone treatment
of episodes of suspected acute opioid overdose. Eur J Emerg Med. 2004;11:19-23
21. Gupta, R., et al. (2016). The Rising Price of Naloxone - Risks to Efforts to Stem
Overdose Deaths. New England Journal of Medicine 375(23): 2213-2215.

9. Naloxone (Narcan) nasal spray for opioid overdose. Medical Letter on Drugs and
Therapeutics 2016; 58(1485):1-2.

Authors' Affiliation: Fox Chase Cancer Center; Temple University Health System;
Philadelphia PA

10. Merlin MA, Saybolt M, Kapitanyan R, et al. Intranasal naloxone delivery is
an alternative to intravenous naloxone for opioid overdoses. Am J Emerg Med. Mar
2010;28:296-303.

Conflicts of Interest: None

11. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for
Chronic Pain - United States, 2016. Jama. 2016;315(15):1624-1645. doi:10.1001/
jama.2016.1464.
12. Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing
patterns and opioid overdose-related deaths. JAMA. 2011;305:1315-1321
13. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain
and overdose: a cohort study. Ann Intern Med. 2010;152:85-92
14. Walley AY, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A. Opioid overdose
prevention with intranasal naloxone among people who take methadone. J Subst Abuse
Treat. 2013;44:241-247.
15. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional
pharmaceutical overdose fatalities. JAMA. 2008;300:2613-2620
16. Coffin PO, Tracy M, Bucciarelli A, Ompad D, Vlahov D, Galea S. Identifying
injection drug users at risk of nonfatal overdose. Acad Emerg Med. 2007;14:616-623.
17. Evans JL, Tsui JI, Hahn JA, Davidson PJ, Lum PJ, Page K. Mortality among young
injection drug users in San Francisco: a 10-year follow-up of the UFO study. Am J
Epidemiol. 2012;175:302-308.
18. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison-a high risk of death
for former inmates. N Engl J Med. 2007;356:157-165.

Version History: Edited by Sean Marks, MD, first electronically published January
2017
Fast Facts and Concepts are edited by Sean Marks, MD, (Medical College of
Wisconsin) and associate editor Drew A Rosielle, MD, (University of Minnesota
Medical School), with the generous support of a volunteer peer-review editorial
board, and are made available online by the Palliative Care Network of Wisconsin
(PCNOW); the authors of each individual Fast Fact are solely responsible for that
Fast Fact's content. The full set of Fast Facts is available at Palliative Care Network of
Wisconsin with contact information, and how to reference Fast Facts.
Copyright: All Fast Facts and Concepts are published under a Creative Commons
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Disclaimer: Fast Facts and Concepts provide educational information for health care
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updated, and new safety information may emerge after a Fast Fact is published.
Health care providers should always exercise their own independent clinical
judgment and consult other relevant and up-to-date experts and resources. Some Fast
Facts cite the use of a product in a dosage, for an indication, or in a manner other
than that recommended in the product labeling. Accordingly, the official prescribing
information should be consulted before any such product is used.

SPRING 2017

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