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Should GPs routinely prescribe naloxone to people who use opioids?
Experts believe this measure may be life-saving, likening it to using an Epipen for anaphylaxis or intramuscular glucagon.
Take-home naloxone has been found to successfully reverse more than 96% of community overdoses.
The rate of fatal opioid overdoses has almost doubled in Australia between 2002 and 2018, and take-home naloxone has been found to successfully reverse more than 96% of community overdoses.
And yet, naloxone is not routinely prescribed to people who use opioids.
These are the issues that prompted Dr Pallavi Prathivadi, a GP and PhD candidate at Monash University, and Associate Professor Suzanne Nielsen, Deputy Director of the Monash Addiction Research Centre, to pen a new opinion piece in the Medical Journal of Australia.
The experts question the logic behind the fact naloxone is not routinely prescribed, and call for the routine co-prescription to people who use opioids.
‘An Australian study reported that 78% of patients on Schedule 8 opioids for chronic non-cancer pain qualified for take-home naloxone,’ they wrote.
‘Yet current national data show that less than 3% of all naloxone supplied is on individual PBS [Pharmaceutical Benefits Scheme] prescriptions, with most naloxone prescriptions accounted for by harm reduction programs.’
The authors note that naloxone’s efficacy as an emergency reversal agent has not been called into question.
‘The evidence of naloxone’s therapeutic effect and life-saving role has resulted in the drug being carried in most emergency medical kits and included on the World Health Organization Model Lists of Essential Medicines,’ they wrote.
Dr Paul Grinzi, a GP with a special interest in addiction medicine, believes the issue is clear-cut.
‘I frame naloxone for patients who are at higher risk of overdose in the same way as I would frame an Epipen for someone who’s at high risk of an anaphylactic reaction,’ he told newsGP.
‘It’s something you prescribe with some discussion around avoidance of the precipitating events and… it’s available in the household in case it’s needed as a life-saving measure while an ambulance is being sorted out.’
Dr Grinzi believes part of the resistance to this idea relates to stigma, saying some of the barriers to naloxone would ‘dissipate’ if the issues regarding opioid use were minimised.
He believes another reason clinicians hesitate to prescribe naloxone when prescribing opioids relates to lack of awareness.
‘Medical education has come a long way but a lot of us haven’t gone through formal training in our previous education where opioids were an issue and opioid overdose wasn’t as much of an issue, so things like naloxone may well have been off the radar for most GPs,’ he said.
‘Part of this is just being aware and being comfortable talking about the risk in a similar way you would talk about the risk of anaphylactic reactions: what contributes to higher risk, how to minimise that and then what to do if you ended up with that reaction.’
The authors of the opinion piece echo these sentiments.
‘The biggest barriers to naloxone prescribing were low levels of awareness about naloxone, and unwillingness by doctors to prescribe it,’ they wrote.
‘This may be driven by incorrect beliefs that patients on pharmaceutical opioids are at low risk of overdose, lack of knowledge, and incorrect patient reporting of actual opioid use.’
The authors agree with Dr Grinzi’s approach of likening naloxone to an Epipen, and say framing the medication in that way, or comparing it to intramuscular glucagon for diabetic patients on insulin, may change people’s attitudes towards its prescription.
‘Changing the narrative around take-home naloxone from “overdose treatment” to “routinely prescribed emergency medication” may help provider attitudes and encourage the normalisation of naloxone prescribing,’ they wrote.
Dr Paul Grinzi likens the use of naloxone for opioid overdoses to using an Epipen for anaphylaxis.
While Dr Grinzi agrees with the authors’ belief it is time to routinely co-prescribe naloxone to patients using opioids, he says that, at the very least, it should be prescribed to patients at higher risk of overdose.
These risks include:
- past history of overdose, whether deliberate or accidental
- using opioids in combination with any benzodiazepine
- history of substance use disorder
- psychiatric and medical comorbidities that impact risk, such as sleep apnoea, liver disease and depression
- those on higher doses of opioids.
‘The risk starts to really increase once we get above 50mg of morphine equivalent per day, and then it really takes off once we get above 100 mg of morphine equivalent per day,’ he said.
Dr Grinzi says if he has a patient he does not believe is at risk of overdose but would like to have naloxone at home, he would not hesitate offering it.
‘I certainly am prescribing it,’ he said.
He says every GP currently has ‘their own threshold’ regarding when to prescribe naloxone, saying some doctors will prescribe routinely for all people who use opioids, while others will only consider initiating it in certain circumstances.
‘Prescription is very simple. It’s on the PBS, it’s widely available,’ he said.
While prescribing naloxone is easy, Dr Grinzi’s focus lies in discussing the implications, saying it is not enough to simply prescribe naloxone to the person taking opioids and household members also need to know the signs of overdose, and when to administer.
‘The common scenario is there is a family member who notices that their relative or housemate is snoring or semi-conscious on the couch,’ he said.
‘What we know is a number of people who’ve died of overdose, the household member reports [the patient was] snoring and they just let them sleep it off and sadly they stop breathing during the night and never get a chance to wake up again.
‘It’s that awareness of someone who’s semi-conscious, maybe sleeping, who’s taking an opioid – whether it’s prescription or illicit, it doesn’t really matter – having awareness of that and instigating some pre-overdose first aid and monitoring and then obviously if someone does stop breathing, knowing what to do.’
The authors hope GPs and pharmacists will consider discussing and co-prescribing take-home naloxone for patients using opioids for chronic pain.
While this may seem like an expensive measure, the authors say each script would cost around $40–50 on the PBS, which they note is comparable to an adrenaline auto-injector or glucagon, both listed at $40.
The authors say ‘normalising’ the role of naloxone will require major changes in attitudes among healthcare providers and within the community.
‘Ongoing collaborative efforts are needed to embrace higher prescribing and dispensing of naloxone,’ they wrote.
‘Australia’s increasing prescription opioid overdoses demands this conversation.’
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