Wider availability and use of the opioid-overdose antidote naloxone can lower the deadly toll of the opioid epidemic. When talking with patients about naloxone, physicians need to be ready to answer patients’ questions, respond to any resistance and work to reduce the stigma that is still often attached to opioid-use disorder and its treatments.
The AMA Opioid Task Force encourages physicians to consider co-prescribing naloxone when clinically appropriate. The AMA’s model state bill includes provisions to increases access to naloxone, provides for liability protections to health care professionals prescribing naloxone, authorizes third-party prescriptions and standing orders to allow persons without a prescription to obtain naloxone from a pharmacy, and includes “Good Samaritan” protections against civil and criminal penalties, including parole violations.
All 50 states now have some sort of law providing varying levels of access to naloxone to prevent overdoses, according to the Prescription Drug Abuse Policy System (PDAPS), a National Institute on Drug Abuse-funded policy-tracking research organization. PDAPS also notes that 46 states now have Good Samaritan drug overdose laws.
U.S. Surgeon General Jerome M. Adams, MD, MPH, issued a public health advisory on naloxone that explains the drug’s benefits, and he followed it up with a JAMA Viewpoint column calling for increasing naloxone awareness and use.
Patrice A. Harris, MD, AMA president-elect and chair of the AMA Opioid Task Force, said the AMA strongly endorses the surgeon general’s advisory.
“Surgeon General Adams, physicians, first responders and public health advocates all recognize that naloxone is a literal lifesaver and a vital tool in our fight against the opioid epidemic,” she said. “Patients, family members and friends should not hesitate to ask their physicians to prescribe naloxone so they can save their own or their loved one’s lives. Many states have made naloxone available without a prescription.”
Eric Ketcham, MD, an emergency and addiction medicine specialist in New Mexico, compares having a naloxone kit at home to having easy access to a fire extinguisher.
“The truth is that, by having naloxone available, we’re acknowledging we have an epidemic,” Dr. Ketcham said. “When you talk to patients about naloxone, most people are relieved you brought it up, and most people are glad you are concerned. Family members are often glad to know we’re taking this seriously.”
Framing the discussion. Donald E. Stader III, MD, president-elect of the American College of Emergency Physicians (ACEP) Colorado chapter, said it’s important to emphasize to patients that opioids carry risks that they need to be aware of. Patients are not being targeted or being accused of being out of control.
“I identify this as a judgment-free zone,” Dr. Stader said. “I tell them, ‘All I care about is your safety, all I want to talk about is your health, and this prescription can save your life or potentially save your friend’s life.’”
Tolerance is moving target. That message is directed primarily at patients with opioid-use disorder. For patients taking opioids for pain, Dr. Stader said he is more likely to emphasize the risks of opioid overdose in their discussion.
“They may say, ‘I’ve been taking opioids for years and I have high tolerance,’ then I respond by saying tolerance waxes and wanes,” Dr. Stader said.
In particular, tolerance to opioids can be lowered significantly after a period of abstinence. Patients who take their customary dosage after not taking opioids for a while are at risk of overdose.
Work together. Dr. Ketcham, a former president of ACEP’s New Mexico chapter, noted that it helps to discuss naloxone with a family member to ensure that this person will be ready to administer the drug should the need arise.
“I tell them naloxone won’t do anybody any good if it sits in a drawer and nobody knows where it is,” he added.
Call for help. Patients and their families also need to know that naloxone may not completely resolve the problems that were created by the overdose. The person who administered the naloxone needs to call 911 because the person who had the overdose still needs medical attention, Dr. Ketcham said.
Enabling conversation. Starting a conversation about naloxone can help initiate a general dialogue on opioid-use disorder with a patient who had been reluctant to discussing it before.
Physicians also need to counter the notion that providing naloxone is enabling drug abuse. Greater awareness about the potential for overdoses and how naloxone can reverse them has led to people “taking less offense at bringing this up,” Dr. Ketcham said, particularly parents of adolescents who may be prescribed opioids for a bone fracture.
“I’m not saying we don’t have to be tactful, but we have to be frank—even if people are initially offended,” Dr. Ketcham said. “The overall objective is to see naloxone prescribed a heck of a lot more often—especially for individuals who are at risk.”
More naloxone resources are available on the AMA End the Opioid Epidemic microsite.