HHS: Prescribe naloxone to patients at high risk for opioid overdose

HHS issued new guidance today that recommends prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose, according to a press release.

“We have begun to see some encouraging signs in our response to the opioid crisis, but we know that more work is required to fully reverse the decades-long epidemic,” Admiral Brett P. Giroir, MD, assistant secretary for health and senior advisor for opioid policy at HHS, said in a press release.

“Co-prescribing naloxone when a patient is considered to be at high risk of an overdose, is an essential element of our national effort to reduce overdose deaths and should be practiced widely,” he continued.

HHS data suggest less than 1% of patients to whom clinicians should consider co-prescribing naloxone actually receive a naloxone prescription. Thus, the agency recommends clinicians strongly consider prescribing or co-prescribing naloxone and providing education about its use to the following patients:

  • those prescribed opioids at a daily dosage of 50 morphine milligram equivalents or more;
  • those prescribed opioids who also have reported excessive alcohol use; have been prescribed benzodiazepines; have a nonopioid substance use or mental health disorder; or have a respiratory condition such as obstructive sleep apnea or COPD (regardless of opioid dose);
  • those who use heroin, illicit synthetic opioids or are misusing prescription opioids;
  • those who use stimulants, including cocaine and methamphetamine, which may possibly be contaminated with illicit synthetic opioids like fentanyl;
  • those who receive treatment for opioid use disorder, including medication-assisted treatment with buprenorphine, naltrexone or methadone; and
  • those who misused opioids in the past and were also recently released from incarceration or other controlled settings where tolerance to opioids has been lost.

HHS also recommends clinicians teach patients, their family members and friends and others who are likely to respond to an overdose on when and how to use naloxone.

The new guidelines build on recommendations released by the CDC in 2016 that were intended to increase the use of effective nonopioid treatments for chronic pain, except in cases of active cancer, palliative and end-of-life care, that were based on the following principles:

  • use only when the benefits outweigh the risks and not as a first-line therapy;
  • establish goals for pain and function;
  • discuss risks and benefits with patients;
  • use immediate-release opioids, rather than extended-release, when starting;
  • use the lowest effective dosage;
  • prescribe shorter durations for acute pain;
  • frequently evaluate benefits and harms;
  • use strategies to mitigate risk;
  • review patients’ Prescription Drug Monitoring Program data;
  • use urine drug testing before starting opioid therapy;
  • avoid prescribing concurrent opioid and benzodiazepine treatments; and
  • offer treatment for opioid use disorder.

Pill Bottles 
HHS issued new guidance today that recommends prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose, according to a press release.
Source:Shutterstock

Since the CDC released its guidelines, the HHS also unveiled a five-point strategy to combat the opioid crisis that included better addiction prevention, treatment and recovery services; better data; better pain management; better targeting of overdose reversing drugs; and better research. In addition, this past April, the Surgeon General’s office issued an advisory that encouraging more individuals, including those who are personally at risk for an opioid overdose, and their family and friends, to carry naloxone. – by Janel Miller

For more information: HHS.gov. “Naloxone: The opioid reversal drug that saves lives.”

https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf. Accessed Dec. 19, 2018.

Disclosure: Giroir works for HHS.

 

HHS issued new guidance today that recommends prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose, according to a press release.

“We have begun to see some encouraging signs in our response to the opioid crisis, but we know that more work is required to fully reverse the decades-long epidemic,” Admiral Brett P. Giroir, MD, assistant secretary for health and senior advisor for opioid policy at HHS, said in a press release.

“Co-prescribing naloxone when a patient is considered to be at high risk of an overdose, is an essential element of our national effort to reduce overdose deaths and should be practiced widely,” he continued.

HHS data suggest less than 1% of patients to whom clinicians should consider co-prescribing naloxone actually receive a naloxone prescription. Thus, the agency recommends clinicians strongly consider prescribing or co-prescribing naloxone and providing education about its use to the following patients:

  • those prescribed opioids at a daily dosage of 50 morphine milligram equivalents or more;
  • those prescribed opioids who also have reported excessive alcohol use; have been prescribed benzodiazepines; have a nonopioid substance use or mental health disorder; or have a respiratory condition such as obstructive sleep apnea or COPD (regardless of opioid dose);
  • those who use heroin, illicit synthetic opioids or are misusing prescription opioids;
  • those who use stimulants, including cocaine and methamphetamine, which may possibly be contaminated with illicit synthetic opioids like fentanyl;
  • those who receive treatment for opioid use disorder, including medication-assisted treatment with buprenorphine, naltrexone or methadone; and
  • those who misused opioids in the past and were also recently released from incarceration or other controlled settings where tolerance to opioids has been lost.

HHS also recommends clinicians teach patients, their family members and friends and others who are likely to respond to an overdose on when and how to use naloxone.

The new guidelines build on recommendations released by the CDC in 2016 that were intended to increase the use of effective nonopioid treatments for chronic pain, except in cases of active cancer, palliative and end-of-life care, that were based on the following principles:

  • use only when the benefits outweigh the risks and not as a first-line therapy;
  • establish goals for pain and function;
  • discuss risks and benefits with patients;
  • use immediate-release opioids, rather than extended-release, when starting;
  • use the lowest effective dosage;
  • prescribe shorter durations for acute pain;
  • frequently evaluate benefits and harms;
  • use strategies to mitigate risk;
  • review patients’ Prescription Drug Monitoring Program data;
  • use urine drug testing before starting opioid therapy;
  • avoid prescribing concurrent opioid and benzodiazepine treatments; and
  • offer treatment for opioid use disorder.

Pill Bottles 
HHS issued new guidance today that recommends prescribing or co-prescribing naloxone and providing education about this treatment in patients at high risk for opioid overdose, according to a press release.
Source:Shutterstock

Since the CDC released its guidelines, the HHS also unveiled a five-point strategy to combat the opioid crisis that included better addiction prevention, treatment and recovery services; better data; better pain management; better targeting of overdose reversing drugs; and better research. In addition, this past April, the Surgeon General’s office issued an advisory that encouraging more individuals, including those who are personally at risk for an opioid overdose, and their family and friends, to carry naloxone. – by Janel Miller

For more information: HHS.gov. “Naloxone: The opioid reversal drug that saves lives.”

https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf. Accessed Dec. 19, 2018.

Disclosure: Giroir works for HHS.

 

    Perspective
    James H. Berry

    James H. Berry

    These HHS guidelines on naloxone are a great step in the right direction. We do need to make life-saving naloxone as readily available as possible to anyone who is at risk for an opioid overdose. Barriers preventing this availability need to be removed and I stand behind HHS 100% on their decision to encourage this.

    However, with these guidelines, the HHS continues to overemphasize opioids role in pain management while neglecting the greater necessity of understanding addiction as a disease which transcends a particular substance and has etiologies that are much broader than physical pain. For instance, more adults die every year from alcohol and tobacco and more adolescents are seen in the emergency room due to cannabis than from opioids. The substances people are using are evolving rapidly, such that methamphetamine and fentanyl have been implicated in the sharpest rise of deaths over the past couple years. Better pain management and responsible opioid prescribing will not significantly impact the vast numbers of people currently suffering from addiction or those likely to develop an addiction unrelated to a pain pill prescription. Physicians need to be given the resources and training to better screen for all addictions and provide the necessary psychosocial interventions to adequately address the disease.

    For opioid use disorder, we desperately need to expand medication-assisted treatment into every community. Ideally, patients should have access to this evidence-based treatment on demand. Clinicians may want to consider the medication-assisted treatment model our health system employs. Ours is a shared medical appointment model that directly links the prescribing of a medication with psychological therapies and community resources. We strive to address the biologic, psychologic and social components of the disease and do so in a way that is financially sustainable. We have been practicing this model for the past fifteen years and have seen much long-term improvement in the lives of our patients.

    It would behoove HHS to consider these types of models and other innovative approaches as well as steer more funding towards the prevention and behavioral health initiatives that are lacking in many U.S. communities. Doing so will make a more significant dent in not only the current opioid crisis, but also the much greater addiction epidemic rampant in our nation.

    • James H. Berry, DO
    • Addiction psychiatrist, associate professor and vice chair of inpatient acute dual diagnosis program
      West Virginia University School of Medicine

    Disclosures: Berry reports no relevant financial disclosures.

    Perspective
    Anthony J. Brutico

    Anthony J. Brutico

    HHS is taking a step in the right direction with these guidelines regarding naloxone. These guidelines are particularly helpful for those patients who higher strength narcotics, or have respiratory issues like COPD or sleep apnea, since they have a tendency to develop dangerous acid-base disturbances that can be exacerbated by high doses of narcotics.

    Though Narcan is helpful, it is not the long-term solution to the opioid crisis. To more completely address this epidemic, we need to be focused on rehabilitative therapy, such as individual or group counseling, combined with medication-assisted therapy like Subutex or Suboxone that bind to opioid receptors in the brain and control withdrawal symptoms, but do not have the euphoric properties that other opioids do.

    Narcan is a great emergency option to opioid overdose. This medication gives patients another chance and in some of these patients, one overdose is enough to convince them that he or she needs to overcome their addiction to opioids. But in a lot of cases it doesn’t, and one in ten people saved by Narcan will die from another opioid overdose within one year.

    Think of it this way: a defibrillator will save many patients from dying from a cardiac arrest, but it does not stop the problems that led to the heart disease in the first place, such as smoking, unhealthy diet, sedentary lifestyle, etc.

    Getting patients into rehabilitation and medication-assisted therapy is the better long-term answer to the opioid epidemic, just as quitting smoking, eating healthier and exercising regularly are a better, long-term answer to better cardiovascular health.

    • Anthony J. Brutico, DO
    • Emergency department medical director
      Atlantic Health System, Newton Medical Center, Atlantic Health System Newton N.J.

    Disclosures: Brutico reports no relevant financial disclosures.

    Perspective
    Eric J. Adkins

    Eric J. Adkins

    All too often in this opioid crisis, many patients with opioid use disorder are seen in EDs across the country. Unfortunately, there are a portion of them that are never seen in the ED because they are found dead. As physicians, we want the opportunity to intervene and help patients, but we need better tools to screen and identify these patients. There are opportunities to proactively identify patients at risk of opiate addiction and its consequences. Thus, it would have been helpful if the HHS had provided guidance in the identifying and screening areas.

    That point aside, these HHS recommendations on naloxone rightly identify those who are not typically considered at risk for opioid use related complications, such as those with COPD and obstructive sleep apnea. Physicians that are prescribing narcotics or caring for such patients that have been prescribed narcotics by another provider may want to take the HHS recommendations one step further. This could be done by leveraging patients’ electronic health records to alert health care professionals when a patient is in one of the groups HHS singled out as particularly at high risk for opioid use disorder and is nearing the daily maximum morphine equivalents per day. Once identified, the health care professional can offer the potential lifesaving medication commonly called Narcan that can reverse the effects of narcotics in the event of an overdose. Patients and families need education on opiate addiction, risks of abuse, and how to use the Narcan as well and then fill any information gaps the patient has. For far too long, these “asks” were not happening, or happening at a level that often left the patient feeling demeaned or degraded.

    In our ED at The Ohio State University Wexner Medical Center, we have been giving patients who come in for opiate abuse related conditions naloxone when they are discharged. We have also been pushing for more physicians to obtain the waiver needed to prescribe medication-assisted therapy and have partnered with community organizations who are interested in helping patients with opioid use disorders quickly and affordably find the resources they need to get their lives back on the right track. Strategies such as these are working in Ohio. If implemented on a broader level, they may finally move the needle in a significant positive direction on the opioid crisis.   

    • Eric J. Adkins, MD, ACEP
    • Department of emergency medicine
      The Ohio State University Wexner Medical Center

    Disclosures: Adkins reports no relevant financial disclosures.

    See more from Opioid Resource Center