BCMSMedicalRecordSpring2017 - 20

M e d i c a l R e c o R d F e at u R e

NALOXONE FOR
OUTPATIENTS AT RISK
OF OPIOID OVERDOSE
by Marcin Chwistek, MD, FAAHPM, and Matthew Wolf, RN, BSN

Background: In the US, approximately 28,000 opioid overdose
deaths occur annually, with at least half of these deaths involving
prescription opioids (1). This Fast Fact discusses the use of naloxone
in the outpatient setting for patients with an advanced illness on
opioid therapy who may be at risk for opioid overdose. See Fast
Fact #39 for further information on naloxone use for inpatient care
settings.
Opioid Overdose in Palliative Care Patients: Previous studies have
suggested that opioid overdoses are infrequent for patients receiving
palliative care (2). In recent years, however, palliative care clinicians
have been more routinely involved in the outpatient treatment
of cancer pain and, in some instances, may also manage pain in
long-term cancer survivors and/or non-cancer pain (2-4). Therefore,
there is concern that many palliative care patients may be at risk
for opioid overdose given their co-morbidities, relatively high doses
of opioids needed to control symptoms, and, in some instances,
a history of substance use disorders (see Fast Facts #127, 310 and
311) (5). There is also an emerging awareness of inappropriate or
excessive use of opioids among patients with cancer-related pain (2).
Naloxone Co-prescribing: In the 1990s, public health and
community organizations initiated naloxone distribution programs
such as the Overdose Education and Naloxone Distribution
(OEND) to prevent opioid overdose fatalities among heroin users
(6). Between 1996 and 2010, naloxone was distributed to 50,000
persons, and more than 10,000 overdose reversals were documented
(7). In many scenarios, bystanders were able to recognize an
overdose from a prescribed opioid and administer naloxone
effectively. Federal agencies from the US, Canada, Australia, and
many European countries have endorsed the provision of outpatient
naloxone as part of a larger strategy to reduce overdose fatalities
from prescribed opioids (6). Co-prescribing of naloxone for patients
on chronic opioids is currently being implemented through the US
Veterans Affairs Medical System (8).
Pharmacology: Naloxone is an opioid antagonist indicated for
the emergency treatment of known or suspected opioid overdose,
as manifested by respiratory and/or central nervous system
depression. A needle-free formulation which is FDA approved for
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the emergency treatment of an opioid overdose is available via a
pre-filled, single dose intranasal spray. Intranasal administration of
naloxone begins to reverse opioid-induced respiratory depression
and sedation in 8-13 minutes; peak effect is 20-30 min.; and the
half-life is about 2 hours (9). The nasal spray is supplied in a box
containing two, 4 mg single-use nasal spray devices. A dose can be
repeated every 2-3 minutes in alternating nostrils, if necessary (8).
In some states, it is available in pharmacies without a prescription.
In a study of patients who received naloxone by paramedics,
intranasal naloxone was found to be noninferior to intravenous
naloxone regarding the reversal of sedation and respiratory rate (10).
Indications For Outpatient Naloxone Prescribing: Coprescribing of naloxone with prescription opioid medications is
still the exception rather than a rule, especially in the palliative
care setting. There is a concern that bystanders may administer
naloxone inappropriately in seriously ill patients when physiological
changes related to disease progression are mistakenly thought to
be related to an overdose. The final decision about co-prescribing
naloxone should be individualized based on a patient's risk profile,
prognosis, care preferences, and the availability of an informed
caregiver. Establishing more rigorous evidence-based criteria for coprescribing is needed, but the following patients may be at risk of
an opioid-related fatality when death from their underlying illness is
not imminently anticipated (6,11):
* Daily morphine equivalent doses of > 100 mg/day (12,13)
* Methadone as a prescribed analgesic (14)
* Benzodiazepines and/or antidepressants in combination with
opioids (15)
* History of unintentional or intentional overdose (16)
* History of a substance use disorder including alcohol or
tobacco (17)
* History of chronic pulmonary, renal, or hepatic disease (12)
* A recent history of incarceration (18)
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