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Without question, naloxone is somewhat of a “miracle drug” in a clinician’s arsenal. It can save people who are on the brink of death, including those jeopardized by a prescription opioid overdose. This opioid-reversal agent has saved thousands of lives. However, despite that simple truth, naloxone has become a polarizing topic. For some, it’s a “wonder drug” that we need to utilize more, while others downplay its benefits and argue we over-utilize it as a “crutch” for our nation’s “opioid epidemic.” Consider the following:

Underuse

Based on the Center for Disease Control and Prevention (CDC) statistics, there were 47,600 deaths related to synthetic opioids in 2017.¹ It is no secret that opioid overdoses have been on the rise for years, an unfortunate consequence of a nationwide “opioid epidemic.” Though there are many other factors contributing to the steady increase in opioid-related deaths, some would argue that the under-utilization of naloxone is a main contributor. Naloxone has the potential to save lives, but several barriers to its use continue to exist:

• Access: While a recent Medicare claims study found that naloxone co-prescribing with opioid prescriptions has more than doubled, likely related to the 2016 release of the CDC Prescribing Opioids for Chronic Pain guidelines,² only 1 in 70 opioid prescriptions is dispensed with naloxone.³ Other access issues include insurance coverage and patient awareness.
• Education: Not only do many patients receive insufficient education about naloxone, but more importantly, we often overlook educating the family or loved ones of those receiving a naloxone prescription. If a patient has overdosed, it is unlikely that he or she will be administering the naloxone, leaving his or her life in the hands of someone else who may have little to no information about how to use naloxone correctly.
• Stigma: Patients are often hesitant to receive naloxone due to the implied likelihood of overdosing. A recent survey within the VA system found that patients avoid naloxone kits due to fear of being labeled “an addict” or “a druggie.”⁴

Overuse

While it can save lives, naloxone prescribing does not address the root issues at play in addiction or overdose. In the famous poem, The Fence or the Ambulance by Joseph Malins, a town is faced with two options to prevent people falling of a roadside cliff: 1) put a fence at the top to prevent falls, or 2) park an ambulance in the valley to treat those who fall. With the obvious better answer to build a fence, the poem provides a simple analogy of the important of prevention. While naloxone saves lives, it is an “ambulance in the valley.” It does not prevent any falls. But for many clinicians, naloxone prescribing is an “easy” fix that helps the prescriber feel safer. However, until we as healthcare providers fully evaluate and improve our prescribing and other habits, patients will continue to “fall off the cliff.” And there will never be enough naloxone ambulances to save those lives.

Which is it?

Naloxone is likely both under- and over-utilized. As pharmacists, we are well-positioned to address the barriers that prevent naloxone from having its maximum benefit. However, we can also ensure our efforts don’t stop with naloxone by advocating and championing for better opioid prescribing habits and appropriate opioid stewardship to decrease the need for naloxone. 

Authors

Nicholas Cox, PharmD, BCACP

Assistant Professor (Clinical), Department of Pharmacotherapy, University of Utah College of Pharmacy

Sabrina Schneider, PharmD

PGY-1 Pharmacy Resident, University of Utah Health

References

1. Drug Overdose Deaths. U.S. Department of Health and Human Services. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Reviewed Jun 27, 2019. Accessed Nov 12, 2019.
2. Life-Saving Naloxone from Pharmacies. Vital Signs. https://www.cdc.gov/vitalsigns/naloxone/index.html. Reviewed Aug 6, 2019. Accessed Nov 12, 2019.
3. Jones CM, et al. Naloxone Co-prescribing to Patients Receiving Prescription Opioids in the Medicare Par D Program, United States, 2016-2017. JAMA. 2019 Aug 6;322(4):462-464. Accessed Nov 12, 2019.
4. Bounthavong M, et al. Providers’ perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment. Research in Social and Administrative Pharmacy. Available Oct 31, 2019 [E-published ahead of print]. Accessed Nov 12, 2019.