Naloxone – Cautions for the Pharmacist
Kristen Jones, PharmD, Risk Management Consultant
In 2013 alone, legal and illegal opioid drugs killed 24,492 people nationwide, including 16,235 who used synthetic opioid drugs such as oxycodone or hydrocodone, and 8,257 others dying from heroin, the CDC reports. Overdose is the number one cause of accidental death surpassing automobile accidents.
In the mid-1990s, community based programs recognized the increasing amount of drug abuse and began offering opioid prevention services to drug abusers, their families, friends and service providers. In 1996, many of these programs added naloxone administration kits and training to their services. Over time naloxone distribution has increased due to the success of these prevention programs. Naloxone is a non-selective, short-acting opioid receptor antagonist that has a long clinical history (about 35 years) of successful use and is presently considered a safe drug over a wide dose range. It takes effect in three to five minutes and its effects last 30-90 minutes.
Risk Management Considerations for Pharmacists When Dispensing Naloxone
Current models for prescribing naloxone fit into one of three categories: prescriber writes a prescription and patient fills it at a pharmacy, prescriber writes prescription and dispenses a prepackaged kit, or the pharmacy provides naloxone directly to customer under a collaborative practice agreement, standing order or in a few states prescribing authority.
The rationale for dispensing naloxone kits is simple. First, most opioid abusers do not use drugs alone and most bystanders (family and friends) are trainable to recognize and respond to drug overdose. Prescribers and pharmacists can identify known risk factors of opioid abusers including history of mixing substances or prior overdose, chronic illness affecting drug metabolism, abstinence (recent drug rehab program) or use of opioids alone. The use of naloxone kits takes advantage of the opportunity window of overdose. The overdose can often take minutes to hours which can be reversed almost immediately with the administration of naloxone. Last, the availability of the naloxone and these education programs can help eliminate bystanders from avoiding reaching out for help in the event of an overdose because of the fear of arrest. Many states have even passed Good Samaritan laws to protect bystanders from arrest in the event of an overdose and naloxone treatment.
When dispensing and subsequently counseling about naloxone for overdose it is important to educate all parties about the risks associated with its use. Risks related to naloxone use in opioid-dependent patients are:
- The induction of an acute withdrawal syndrome which may cause nausea and vomiting resulting in aspiration or choking.
- The effect of naloxone may wear off prematurely when used for treatment of opioid-induced respiratory depression especially when long acting opioids are the cause of the overdose.
- Less commonly in patients treated for severe pain with an opioid, high-dose naloxone and/or rapidly infused naloxone may cause catecholamine release and consequently pulmonary edema and cardiac arrhythmias.
Because of these risks it is important that all patients, family, friends and caregivers understand the important steps in the event of an overdose. These steps should be communicated upon dispensing all naloxone kits.
- Recognize the overdose
- Call 911 for help
- Initiate rescue breathing
- Administer naloxone and continue rescue breathing, re-administer dose if no response in 3-5 minutes
- Wait for help to arrive
More detailed patient counseling information can be found at opioidprescribing.com.
Naloxone kits have the potential to save thousands of lives each year. Rules differ from state to state in terms of prescribing, dispensing, third party dispensing and reporting. It is important to review the current status of naloxone distribution in your state.
Community-Based Opioid Overdose Prevention Programs Providing Naloxone ”” United States, 2010 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm
Legal Aspects of Providing Naloxone to Heroin Users in the United States http://prescribetoprevent.org/wp-content/uploads/2012/11/burris_legalaspectsofprescribing.pdf