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Has Heroine Use Increased Since Narcan Was Invented

Written By Sunday, April 17, 2022 Add Comment Edit

Clinical scenario: Upon filling a prescription for oxycodone, a chemist reviews the patient's other medications: "In the Prescription Monitoring Program, I see that yous're also existence prescribed clonazepam past some other physician. I wanted to brand certain that y'all understand that combining pain medications, like oxycodone, and anxiety medications, similar clonazepam, tin can increase your risk of drowsiness, sedation, and even overdose." The patient replies that she has been taking these medications for a long time and is not concerned. "I'm glad to hear that you're aware of the risks," the pharmacist says, "With your permission, I'm going to contact your prescribers, and then we can monitor your run a risk and keep you condom."

EPIDEMIOLOGY

Drug overdose, driven largely by use of prescription opioids and heroin, is now the leading crusade of accidental injury death in the United states, surpassing those caused by motor vehicle crashes (U.Southward. Food and Drug Assistants, 2022; U.S. Centers for Disease Command and Prevention, 2022a, 2022b). From 2005 to 2022, annual opioid-related overdose deaths almost doubled, from 12,937 to 24,492 (Jones et al., 2022; Wheeler et al., 2022). The economic costs to social club take been projected to surpass $twenty billion every year (Inocencio et al., 2022). This overdose crunch has been linked to the availability and authorization of prescribed opioids (Okie, 2010; Modarai et al., 2022; Chen et al., 2022; Dart et al., 2022). Whereas 71% of those who are at chance to misuse pain relievers report obtaining the medications from family and friends, 79% of those family and friends report being prescribed those medicines by their physician ( Substance Abuse and Mental Wellness Services Assistants, 2022). Both qualitative and epidemiologic studies have also demonstrated that heroin addiction is often preceded by prescription opioid misuse (Jones, 2022; Dasgupta et al., 2022; Mars et al., 2022; LaRochelle et al., 2022). Furthermore, fentanyl-related overdose fatalities accept increased, involving fentanyl manufactured and distributed illicitly as part of the street drug market (U.Due south. Centers for Disease Control and Prevention, 2022c).

How Does an Opioid Overdose Occur?

Opioid receptors are found throughout the nervous organization, including the sections of the brainstem that command breathing. Stimulation of the receptors by opioids can cause euphoria, pain relief, sedation, and decreased respiration. High doses of opioids cause reduced sensitivity to oxygen and carbon dioxide levels, reducing respiratory drive and assuasive tidal volume and respiratory charge per unit to subtract. The resulting hypoxia tin can cause a loss of consciousness, and eventually, death. Signs of an overdose include decreases in respiratory rate, abnormal breathing sounds (snoring, gurgling, choking, etc.), decreased consciousness, miosis, and a blueish/gray tinge of the skin, peculiarly the lips and nail beds (White and Irvine, 1999).

PREVENTION

What are Common Risks for Opioid Overdose?

Medical providers and pharmacists should understand, explicate to patients, and take actions to reduce overdose risk. The following should be considered when assessing a patient's take chances.

First, previous nonfatal overdose is associated with futurity overdose (Kinner et al., 2022). Second, higher opioid doses, such as daily doses higher than 50 morphine milli-equivalents (Dunn et al., 2010), and changes in dose or formulations increment overdose risk; people who use heroin are thus often at chance due to unpredictable changes in substance purity from, for case, adulteration with fentanyl (Rudd et al., 2022). Third, polypharmacy and mixing substances contribute to overdose risk, equally opioid overdoses commonly involve other substances (Jones et al., 2022, 2022). Psychoactive medications of item business organization include barbiturates, stimulants, and benzodiazepines (Jann et al., 2022 ; Zedler et al., 2022 ; Jones and McAninch, 2022). Other medications that can have synergistically central nervous arrangement depressive effects include clonidine (Beuger et al., 1998), promethazine (Shapiro et al., 2022; Lynch et al., 2022), and gabapentin (Smith et al., 2022). Fourth, socially isolated individuals who use prescription opioids or heroin alone take footling gamble of being rescued. Isolation is also associated with low, which is itself associated with overdose (Cacioppo et al., 2006; Madadi et al., 2022). Fifth, chronic medical illnesses involving organs, such as the lung, liver, kidney, and brain, primarily responsible for metabolizing substances and respiration, can compromise the body'due south ability to handle opioids (Zedler et al., 2022). Sixth, periods of abstinence, such equally periods of incarceration, hospitalization, and medical detoxification, crusade reduced opioid tolerance and thus increased overdose risk. Accordingly, providers should educate and monitor patients restarting opioids or at take chances of relapse (Wolff, 2002; Strang et al., 2003; Moller et al., 2010).

Assessing a Patient'due south Overdose Risk

Prescribers should assess overdose chance every bit part of a patient'south history by the following ways: reviewing medications and checking the Prescription Monitoring Plan (PMP); reviewing medical and social history for above-mentioned risk factors; obtaining a focused substance apply history; and obtaining an overdose history. The overdose history should determine if the patient has personally experienced an overdose ("Have yous ever overdosed? What strategies do you lot use to prevent yourself from overdosing?"), witnessed an overdose ("Have you witnessed an overdose?"), or received training to prevent, recognize, and/or respond to one ("How would yous respond to an overdose?"). Understanding the patient'south experience and noesis should guide the education provided.

Pharmacists should review medications, optimize medication prophylactic, and provide patient education. This includes checking the PMP for psychoactive or sedating medications, addressing potential drug–drug interactions, ensuring that prescribers are enlightened of the patient'south prescriptions, confirming understanding of the risks of opioids, providing overdose educational activity, and filling naloxone prescriptions, or, when permitted, directly providing naloxone to the patient.

The pharmacist calls the principal intendance doctor: "I saw your patient has prescriptions for both oxycodone and clonazepam and informed her of the risks of combining these medications" The doctor replies, "I was non aware of the clonazepam prescription. Who is the prescriber?" The pharmacist offers the other prescriber's proper name, which the medico recognizes. "That makes sense. He's a psychiatrist that I refer my patients to. I'll discuss the risks with the patient at our appointment coming upward."

Strategies to Address Overdose

In that location are several existing strategies that address the Department of Health and Humans Services' priority areas of improving opioid-prescribing safe and admission to medication-assisted handling (U.S. Department of Health and Human Services, 2022). Prophylactic opioid-prescribing didactics has been supported by the Federal Drug Administration (FDA) and is mandated in some states similar Massachusetts for prescribers to be relicensed (U.Southward. Food and Drug Administration, 2022). PMPs permit for prescribers and pharmacists to monitor what controlled substances a patient is filling at the pharmacy (Paulozzi et al., 2022; Davis et al., 2022a). Show of their effectiveness as overdose prevention tools is yet mixed (Li et al., 2022; Green et al., 2022a). Prescription drug disposal in many communities occurs at kiosks, frequently hosted at local police stations and other locations, with support from Drug Enforcement Administration (DEA) which holds nationwide "take-back" events (Greyness and Hagemeier, 2022; U.S. Drug Enforcement Administration, 2015). The DEA at present as well permits manufacturers, distributors, handling programs, pharmacies, and healthcare facilities to become authorized collectors of prescription medications (U.South. Drug Enforcement Administration, 2022). Finally, medication for opioid use disorders, specifically methadone, buprenorphine, and naltrexone, is supported by bear witness for increased abstinence and decreased opioid use (Schwartz et al., 2006; Mattick et al., 2009; Krupitsky et al., 2022; Mattick et al., 2022). Methadone and buprenorphine treatment is also associated with decreased criminal activity (Bell et al., 1997; Dolan et al., 2005; Lobmann and Verthein, 2009; Bukten et al., 2022; Soyka et al., 2022), improved birth outcomes (Johnson et al., 2001; Fajemirokun-Odudeyi et al., 2006; Meyer et al., 2022), and less overdose (Langendam et al., 2001; Clausen et al., 2009; Schwartz et al., 2022).

"Your pharmacist contacted me about the risks of taking both clonazepam and oxycodone," the md informs the patient at their appointment. The patient does non understand the business organization. The doctor explains that these medications have interactions that increase the take a chance of drowsiness and overdose, especially if she uses substances like alcohol or other drugs. "Do you ever feel drowsy or sedated from your medications?" The patient acknowledges i consequence when she took an extra oxycodone and clonazepam, after which her husband had trouble waking her upwards. The patient says that she now never takes anything more than than what she is prescribed, and knows to call the doctor if she is struggling with pain, and her psychiatrist if she is struggling with her anxiety.

When the medico asks how she stores her medication, she reports that she has started hiding pills from her son, "He got his wisdom teeth out and was given pain medication, and and then he sprained his ankle and was given even more than. I'm worried he has a drug problem and has switched over to heroin." According to the patient, on previous occasions after leaving treatment, he immediately relapsed, and she is now worried about him overdosing. The medico reiterates the risk of overdose following a period of abstinence, and asks if she has a plan if her son should overdose. The patient says that she knows to phone call an ambulance and start rescue animate, "Only what else can I practice?"

RESPONSE

What are Naloxone Rescue Kits?

Naloxone is an opioid antagonist that displaces opioids from brain receptors and restores breathing and consciousness. Naloxone is a prescription medication, merely not a controlled substance. It normally takes 2 to 5 minutes to accept consequence and wears off later on 30 to 90 minutes, so patients on long-acting opioids like methadone and extended-release oxycodone may take recurrent reduced respirations and overdose (Chamberlain and Klein, 1994). Overdose responders should be encouraged to stay with the person overdosing after assistants of naloxone. In cases of polysubstance or loftier potency fentanyl-related overdose, standard doses of naloxone may be insufficient, and thus rescue animate and assist from the emergency medical providers may be necessary to contrary the overdose. Administering naloxone may precipitate withdrawal symptoms in the victim.

In that location are multiple reasons to equip people in the community with a naloxone rescue kit. Beginning, most opioid users do not apply alone, and then have people effectually them that can arbitrate should an overdose occur (Baca and Grant, 2007; Powis et al., 1999). Second, risk factors for overdose have been identified, as discussed above. Third, the extent of hypoxic brain injury is time-dependent, and then the sooner hypoxia is reversed, the better (Michiels, 2004). Fourth, bystanders tin can be trained to recognize and reply effectively to overdoses with naloxone (Green et al., 2008; Clark et al., 2022). Finally, fear of being arrested sometimes discourages bystanders from calling for medical assistance, and thus makes naloxone an of import tool for people hesitant to phone call for help (Davis et al., 2022).

Naloxone rescue kits have been endorsed past numerous organizations, including the American Medical Association (American Medical Association, 2022), American Social club of Addiction Medicine (American Society of Addiction Medicine, 2022), American Pharmacists Association (American Pharmacists Association, 2022), Substance Abuse and Mental Wellness Services Administration ( Substance Abuse and Mental Wellness Services Administration, 2022), World Health Organization (Earth Health Organisation, 2022), and United Nations Part on Drugs and Offense (United Nations Office on Drugs and Crime, 2022). In 2022, the American Middle Association published guidelines on opioid overdose response with naloxone in an update to their guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (Lavonas et al., 2022, Figure 1).

F1
FIGURE 1:

American Centre Association Opioid-Associated Life-Threatening Emergency (Adult) Algorithm. Reprinted with permission. Apportionment. 2022;132:S501-S518. © 2022 American Heart Clan, Inc. (http://circ.ahajournals.org/content/132/18_suppl_2/S501.long).

What Bear witness Exists to Support Overdose Prevention Didactics and Naloxone Rescue Kits?

Overdose pedagogy and naloxone distribution programs have existed since the belatedly 1990s as community-based initiatives based out of impairment-reduction programs (Maxwell et al., 2006; Sporer and Kral, 2007; Wheeler et al., 2022). Betwixt 1996 and 2022, community organizations reported providing naloxone rescue kits to 152,283 laypersons and received reports of 26,463 overdose reversals (Wheeler et al., 2022).

Studies take shown feasibility of naloxone rescue kits in several unlike populations (Piper et al., 2008; Doe-Simkins et al., 2009; Enteen et al., 2010; Bennett et al., 2022; Walley et al., 2022a). Nonmedical bystanders can exist effectively trained to respond to overdose (Green et al., 2008; Tobin et al., 2009; Wagner et al., 2010). Some take expressed concern that naloxone availability would effect in increased opioid apply, merely this has non been observed. Drug treatment rates have either stayed constant or increased (Seal et al., 2005; Doe-Simkins et al., 2022). In several communities in which programs were implemented, overdose rates have decreased (Maxwell et al., 2006). In Massachusetts, where there was heterogeneous rollout of overdose prevention programs, communities with naloxone distributed to one to 100 people per 100,000 population saw opioid overdose death rates subtract by 27%, whereas in communities with naloxone distributed to over 100 people per 100,000 population, opioid overdose expiry rates declined by 46% (Walley et al., 2022b). In a 2022 written report, a best-instance scenario determined a toll of $438 per quality-adjusted life year (QALY) gained, whereas in the worst-example scenario, the cost was $14,000 per QALY gained (Coffin and Sullivan, 2022).

Talking with Patients About Overdose Prevention and Response with Naloxone

Messages that providers can convey to patients:

  • Only accept opioids prescribed to you and every bit directed;
  • If y'all are worried about your use of opioids, you tin talk to me about it;
  • If you lot are non taking opioids safely, I can aid you detect treatment;
  • Make certain your prescribers and chemist are aware of all of your medications;
  • Don't mix opioids with other drugs or alcohol;
  • Shop medication in a safety and secure identify, and dispose of unused medication;
  • Abstinence can change tolerance, so if you stop taking opioids, a lower dose may exist needed upon restart;
  • Teach friends and family how to respond to an overdose, including how to employ naloxone and where you shop it;
  • Know how to recognize and answer to an overdose when yous witness one.

The medico provides guidance for the patient and her son. "Outset, I'd like to monitor your medications more closely. I'chiliad going to phone call your psychiatrist to discuss whether we should adjust your medications to something safer. I also recommend that you employ a lock box, which you tin can get at the chemist's, to secure your medications." The dr. then devises a plan for her son. "Ask him to consider a handling program that includes a medication for opioid addiction, similar methadone or buprenorphine—here is a carte du jour to contact the handling hotline. Lastly, for both y'all and your son, I'm going to prescribe a naloxone rescue kit. The kit includes a medication called naloxone, and comes with instructions on how to recognize and respond to an overdose."

Naloxone Rescue Kits at the Pharmacy: Prescribing, Stocking, Filling, and Billing

Prescribing naloxone rescue kits should be a collaborative effort betwixt prescribers and pharmacists. Both have the duty to recognize and mitigate overdose risk.

About major wholesalers carry naloxone formulations (Table 1). Outside of the inpatient setting, the most mutual methods of naloxone administration are intranasal and intramuscular. Evzio is an intramuscular formulation of naloxone in the class of an auto-injector (Beletsky, 2022).

T1
Tabular array 1:

Naloxone Formulations and Features

To maintain its shelf life of 12 to 18 months, the production should just be drawn (for the intramuscular injection) or screwed (for the intranasal spray) into the syringe immediately before utilise. To maintain the shelf life, shop at room temperature, avoid environments with fluctuating extreme temperatures like within unattended automobiles, and away from direct light (International Medications Systems Limited, 2022). Previously, the only selection for intranasal naloxone was with the use of the intramuscular formulation with a luer-lock mucosal atomizer device (MAD), which must be stocked separately and does not have a national drug code. However, in November of 2022, the FDA approved a nasal naloxone spray, which requires no assembly (U.S. Nutrient and Drug Administration, 2015). It is important to consider the patient's private preferences and needs when choosing between naloxone formulations.

A growing number of public and private insurers are roofing naloxone formulations. Pharmacists can determine coverage and prior authorization requirements. The cost of naloxone varies by conception and distributor, but is around $40 to $150 for an intranasal regimen—less for the intramuscular regimen, more for the auto-injector—which may place them out of reach for many uninsured patients (Massachusetts Section of Public Health, 2022). Kaléo, the manufacturer of the machine-injector (Evzio), has a patient help program that limits the out-of-pocket cost for eligible patients (Evzio, 2022). The MAD has an out-of-pocket price of around $5 each.

3 models exist for accessing naloxone rescue kits through a pharmacy (Light-green et al., 2022b). First, a prescriber can write a prescription for naloxone and the patient can fill it at the chemist's. In that location, pharmacists tin determine if naloxone is covered by the patient's insurance. Pharmacy staff should demonstrate the assembly and use of naloxone, and besides provide further information on how to prevent, recognize, and respond to overdoses. 2d, prescribers can write a prescription and, if permitted by state law, dispense the naloxone onsite. Third, pharmacies can provide naloxone directly to the patient via a chemist prescriber, or under a continuing society, protocol, or collaborative practise agreement (CPA), explained in more item beneath. In states that do not permit standing orders, protocols, or CPAs, pharmacists can contact the prescriber to have him or her call in or electronically send a prescription.

Variability exists beyond the country regarding availability and regulation of naloxone. Providers are encouraged to identify pharmacies in their areas that stock naloxone, and be aware of their land-specific laws surrounding naloxone prescribing.

The patient visits the pharmacy to pick up her naloxone. The patient asks for some aid to determine which is all-time for her. "I'd be happy to demonstrate," the pharmacist replies.

The Legal Surround for Naloxone Prescribing and Dispensing

The legal surround for naloxone prescribing is in full general no different than that for any other prescription medication. Prescribers must ensure that prescriptions are issued in good religion, in the usual grade of professional person practise, and for a legitimate medical purpose (Abood, 2010). The prescription of naloxone for a patient at risk of overdose satisfies all three criteria (Burris et al., 2009).

Whereas intranasal apply with a MAD is technically considered an off-label use of the intramuscular formulation, prescription of the medication for intranasal administration does not modify liability take a chance. Depending on the setting, 20% to 80% of all prescriptions are written off-label, and the utilize of naloxone intranasally is a well-established practice (O'Reilly and Dalal, 2003; Kerr et al., 2009; Wittich et al., 2022). A contempo review of relevant law discovered no instances in which a prescriber or dispenser was sued for prescribing or providing naloxone for customs use (Davis et al., 2022a). As with any medication, both prescriber and pharmacist should ensure that the patient understands the indications of the medication, possible side effects, and how to administer it in the event of an overdose.

Equally legislators have realized the demand to increment naloxone access to laypersons, the majority of states accept implemented laws and regulations to expand opportunities for naloxone prescription and distribution. Additionally, a number of states have passed laws that limit civil and criminal liability for prescribers, dispensers, and administrators, and also "Good Samaritans" who call for aid in an overdose emergency, and the overdose victim (Davis et al., 2022; Davis and Carr, 2022).

Third Political party Prescribing

In recognition of the fact that the person who is at risk of overdose is frequently not the person that the clinician encounters (ie, ofttimes a friend or family member expresses business concern to the prescriber about another person at chance), a number of country legislatures have taken action to permit prescribers to prescribe naloxone to people with whom they do not accept a prescriber–patient relationship. This is termed "third party prescribing." In a state that allows for third party prescribing, the legal risk in doing so is no different than that if the prescriber were prescribing directly to the person at run a risk. Typically, the bodily prescription will be written in the proper name of the person who has straight contacted the prescriber. Every bit of September 2022, 37 states had passed laws permitting third political party prescribing of naloxone. The question of whose insurance gets billed for 3rd political party prescriptions is an unresolved issue and policies currently differ from place to place.

Enhanced pharmacy access

Some pharmacists practicing in federal agencies such as the Indian Health Service and Veterans Assistants have prescribing authority, and several states have recently passed laws that permit some pharmacists to prescribe naloxone (U.South. Department of Health and Human Services, 1996; Clause et al., 2001; Davis and Carr, 2022). Where the pharmacist is the prescriber, he or she is generally bound by the same requirements that use to physicians and other prescribers.

A majority of states have passed laws that permit prescribers and pharmacists to establish CPAs or standing or protocol orders for naloxone. In these states, a pharmacist can dispense naloxone to whatever individual who meets criteria specified in the understanding or order. Rules and requirements are land-specific, though all states require a written understanding between prescriber and the pharmacy or pharmacist that sets out the terms. As of September 2022, 27 states permit chemist's shop continuing orders and 12 likewise permit naloxone to be distributed by laypersons acting under the authorization of a prescriber at locations such as community-based organizations and drug treatment centers (Davis et al., 2022b ; Wheeler et al., 2022). In many states, standing orders are also used to authorize nonmedical kickoff responders such every bit firefighters and police officers to possess and administer naloxone (Davis et al., 2022b, 2022a).

Amnesty for Prescribers and Dispensers

Fear of legal consequences may still discourage some medical professionals from issuing naloxone prescriptions (Beletsky et al., 2007). To address this concern, 32 states accept changed their laws to provide full or fractional civil immunity to medical professionals who prescribe naloxone equally permitted by law, whereas 30 provide such immunity to dispensers and 36 to the person who administers the medication in the consequence of an overdose. Virtually of these laws require that the medical professional non act negligently or recklessly in prescribing or dispensing. Because of these laws, prescribing or dispensing naloxone entails less risk in most states than prescribing or dispensing other medications.

Good Samaritan Laws

Many people who use illicit drugs or medications other than prescribed may be wary of calling 911 in an overdose for fear of criminal sanctions. Overdose Skillful Samaritan laws, sometimes known as medical amnesty laws, are intended to encourage bystanders to call for help past providing limited criminal immunity to the person that makes the call, and also to the victim. This amnesty is typically limited to relatively minor crimes, although in some states it extends to violations of probation or parole. For prescribers and pharmacists, information technology is important to allow patients prescribed naloxone know of these laws, and reinforce the importance of non only administering naloxone, but also calling emergency medical response (Tobin et al., 2005; Lagu et al., 2006; Pollini et al., 2006).

Country-specific naloxone laws can be found at the Public Health Law Research Program's Law Atlas (www.lawatlas.org).

CONCLUSIONS

Prescribers and pharmacists should acknowledge and embrace their role in helping patients to prevent and respond to opioid overdoses. Clinical and legal environments accept become more conducive to providing overdose prevention education and naloxone rescue kits. Engaging prescribers and pharmacists is crucial to addressing the overdose epidemic.

Acknowledgments

The Web site www.prescribetoprevent.org is a free online resource to help health care providers educate their patients to reduce overdose risk and provide naloxone rescue kits to patients. We would similar to thank the contributors to the Web site.

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Keywords:

pain; prescription drug abuse; prevention; public health; substance abuse

Copyright © 2022 American Society of Addiction Medicine

Has Heroine Use Increased Since Narcan Was Invented,

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