Naloxone Prescription Law Gives More People a Chance to Save a Life
Public Health Feature — October 2015
Tex Med. 2015;111(10):41-47.
By Joey Berlin
Old spy movies and television shows make it look so easy: When someone gets poisoned, someone else shouts something to the effect of "Give him the antidote," and a magic vial or injection saves the victim's life in the nick of time.
It rarely works like that in the real world, which is why physicians don't often toss around the word "antidote." But for opioid users in danger of dying from an overdose, the opioid antagonist naloxone has that rare restorative power. As Dallas anesthesiologist and pain management specialist C.M. Schade, MD, puts it, naloxone is "one of the few true antidotes in medicine."
Until this past summer, opioid users in Texas could receive the potentially lifesaving drug only in a medical care setting. But thanks to a law that took effect Sept. 1, physicians can now prescribe an opioid antagonist to a person in danger of experiencing an opioid-related overdose or to anyone who might be able to help the opioid user. The language essentially allows physicians to empower the user, the user's family and friends, or someone else to administer the naloxone right where an overdose occurs. The expanded access to naloxone comes as a result of Senate Bill 1462 by Sen. Royce West (D-Dallas). On June 18, Gov. Greg Abbott inked his approval of the bill, which the Texas Medical Association strongly supported.
Now, doctors need to know the option is out there. That's why TMA's Council on Science and Public Health and the council's Task Force on Behavioral Health are developing a program to educate physicians, emergency medical services (EMS) professionals, and others on what they need to know about the new law.
"We want to increase awareness not only in the medical community, but also in the public at large and those who are first responders, whether they be police or EMS, [and get] that information out," said Dr. Schade, a member of the Task Force on Behavioral Health.
Safe and Effective
Under the new law, a person can administer naloxone either by intravenous or intramuscular injection or by intranasal spray. A 2009 study in the American Journal of Public Health says the nasal administration of the drug is a safe and effective method, and administering the intramuscular injection "requires little skill."
Like Dr. Schade, David Lakey, MD, former commissioner of the Texas Department of State Health Services (DSHS), doesn't hesitate to brand naloxone as an antidote. Dr. Lakey, a member of the Council on Science and Public Health, also isn't afraid to use another ringing A-word for naloxone, calling the drug "amazing."
"I remember very vividly patients I had who were unresponsive in the hospital, and you're trying to figure out what was the problem," Dr. Lakey said. "I gave them naloxone, and within less than a minute, they were wide-eyed and responsive, and you went from intubating somebody to [the patient] having a conversation with you. So it is a true antidote."
Earlier this year, a U.S. Centers for Disease Control and Prevention (CDC) study on the administration of naloxone by EMS professionals found allowing more EMS staff members to administer the drug might save lives.
As of 2014, CDC says, just 12 states allowed basic EMS staff to administer naloxone for a suspected opioid overdose, although all 50 states allowed advanced EMS staff to administer the drug to reverse an overdose. The study found the rate of opioid overdose death in rural areas was 45 percent higher than in urban areas. But in rural communities, EMS staff used naloxone just 22.5 percent more than in urban areas.
CDC statistics show 22,767 people in the United States died of prescription drug overdoses in 2013, with more than 16,000 of those deaths (71.3 percent) involving opioids. (See "Opioid Overdoses Take a Toll.")
A November 2014 World Health Organization report, Community Management of Opioid Overdose, includes guidelines recommending naloxone become available to opioid users, their friends and family, and anyone else likely to witness an opioid-related overdose.
According to a joint report by the Council on Science and Public Health and the Task Force on Behavioral Health, 26 states and the District of Columbia have taken steps to support urgent care to prevent overdose deaths, including adopting laws that improve access to naloxone.
"Studies indicate that naloxone does not encourage more drug use and there are no effects from taking naloxone if no narcotic is present in the body," the report says. "States with naloxone legislation typically offer videos or other training for families or the public on giving naloxone. Physicians prescribing naloxone for a patient are encouraged to share information with the patient's friends and family on use of naloxone."
The council and task force joint report recommended TMA advocate physician liability protections and programs to reduce drug overdose fatalities by allowing first responders to administer opioid antagonists and by allowing physicians to prescribe naloxone to family members and friends of patients using opioids. The report also recommended TMA implement a plan to promote physician awareness and participation in pain relief education programs.
TMA's House of Delegates took those recommendations, and TMA subsequently supported SB 1462. In addition to allowing physicians to prescribe opioid antagonists, the bill provides liability protections for those physicians. SB 1462 shields a good-faith prescriber from criminal or civil liability for writing the prescription, or for "any outcome resulting" from the administration of the drug.
A Neighbor's Endorsement
Texas has a drug overdose death rate below the national average, with CDC reporting 9.6 overdose deaths per 100,000 population in 2010. The national average was 12.4 deaths per 100,000 population.
Medicine would like to see those numbers drop even lower.
During his eight-year tenure as DSHS commissioner, Dr. Lakey says the department witnessed what other states were doing to expand access to naloxone — including neighboring Oklahoma, where naloxone became available over the counter this year.
Terry Cline, PhD, Oklahoma's commissioner of health, says the Sooner State's progress on naloxone came after a Prescription Drug Fatality Task Force began looking at ways to address Oklahoma's opioid problem. A 2014 CDC report, using 2012 statistics, ranked Oklahoma fifth in the nation in prescribing opioid pain relievers, and in 2010 the state had the fourth-highest unintentional poisoning rate in the nation.
The task force recommended increasing naloxone's availability to help reverse overdoses. In 2013, Oklahoma's legislature passed a law allowing for prescriptions of naloxone to family members of someone who has a chance of overdosing. The same bill also allowed first responders to administer naloxone without a prescription if a person appeared to be overdosing.
Last year, the Tulsa Police Department trained its officers to administer naloxone as part of a pilot program through the state's Department of Mental Health and Substance Abuse Services. The pilot program was successful enough that the Oklahoma City Police Department also participated. Now, naloxone is available without a prescription in Oklahoma. In June, The Oklahoman reported 34 pharmacies in the state carrying the drug.
Dr. Cline says while there's no single "silver bullet" to battling Oklahoma's opioid problem, the task force wants greater naloxone availability as part of a comprehensive approach.
"We're just beginning to better understand our data from the EMS administration of naloxone, and what we know from anecdotal experience … is that a relatively good number of individuals who were involved in those naloxone reversals do end up getting referrals to treatment," he said. "And then there's a segment of those individuals who actually go and comply with treatment."
He says the availability of naloxone for friends and family members of a drug user is a major step for Texas to take.
"Putting it in the hands of family members, we think, will be a huge plus," Dr. Cline said. "[If] you have a family member who you know is at much greater risk because of their drug use for overdose, then it makes sense to have it there and have it available. We think it'll be lifesaving, so it's exciting that Texas is increasing their ability along that continuum as well."
Not Just an Addict's Problem
Naloxone isn't just effective for reversing overdoses, and it can help others besides chronic drug abusers. But physicians say there's a misconception about the drug.
"Quite often, we just think that the only people who are at risk for that is people who are substance-addicted. But that's not the only [group it can help]," said Les Secrest, MD, chair of the TMA Task Force on Behavioral Health.
The U.S. National Library of Medicine notes that naloxone injections can also reduce the effects of opiates a patient receives before surgery, and physicians can administer it to newborns to lessen the effects of opiates the child's mother takes before delivery. The national rise in cases of neonatal abstinence syndrome (NAS) also illustrates a greater need for naloxone availability.
NAS occurs when a fetus or newborn experiences withdrawal because of the mother's drug use. An analysis in the New England Journal of Medicine found that from 2004 to 2013, NAS incidences in neonatal intensive care units in the United States nearly tripled, going from seven to 27 cases per 1,000 admissions.
Austin obstetrician-gynecologist Kimberly Carter, MD, says pregnant mothers whose in-utero children have NAS are prime candidates to benefit from an emergency naloxone treatment. Dr. Carter says bystanders shouldn't hesitate to administer naloxone injections to a pregnant woman if the need arises because "if something bad happens to the mom, something bad is going to happen to the fetus."
"Patients who abuse narcotics, prescription or otherwise, rarely are going to present to a physician's office impaired enough for us to recognize the drug abuse," Dr. Carter said. "This means that the opportunity to save these pregnant women is going to come from their family and friends who know that they are abusing and are at risk and who will thus arm themselves with naloxone to use in case of an emergency."
Also, Drs. Schade and Secrest say many opioid overdoses are accidental and don't mean the user was an addict.
"You can have [situations] where I might be on my usual opioid to manage pain, and then some other medication is introduced that might change the metabolic rate of it," Dr. Secrest said. "Or you might find somebody who's confused and thinks, 'Well, I didn't take my medication,' when they did, and gets an overdose from that type of confusion."
For overdose victims who are addicts, Dr. Cline says naloxone gives them the opportunity to reverse not just the overdose but also the course of their lives.
"One argument against naloxone treatment is that you're just enabling people to continue to use drugs," Dr. Cline said, "which is frustrating because really what we're doing is providing people with another opportunity to get into treatment, get on that road to recovery. For some people, that is the wake-up call, just like a heart attack is a wake-up call for people with high blood pressure or other problems they've been neglecting."
Getting the Word Out
The Council on Science and Public Health and the Task Force on Behavioral Health want to highlight opioids so physicians become more familiar not only with naloxone but also with the seriousness of the opioid overdose epidemic. A list of resources for physicians is available on the TMA website.
Dr. Secrest says TMA publications and videos would be potential education avenues as the council and task force work to get the word out about the implications of SB 1462.
"I think some docs, particularly the docs in the pain management area, have a pretty good idea of what this will allow them to do in terms of making the naloxone available," he said. "But the rest of us, then, are probably a little more in the dark, and [that's] where you'd like to really get primary care involved."
Dr. Schade says he'd like to see public service announcement spots on naloxone and possibly a continuing medical education (CME) package, such as an update to the current CME course titled Pain Management: Accidental Lethal Drug Overdoses. (See "Pain Management CME.") Dr. Lakey says TMA's efforts should stress the importance of screening patients by asking them questions related to their drug habits so they can find the patients who could benefit from the rescue therapy naloxone provides.
He says the education should address questions like, "You have a patient that has used this medicine, what do you do next? Now that you know that [the patient] has had a life-threatening event because of overdose, what are we going to advise physicians to do next so that we can get those folks into ongoing treatment?" Doing so, Dr. Lakey says, will help prevent drug abusers from using naloxone as a "crutch to continuously overdose."
"All of us would love to have people to have been 100 percent successful in getting off heroin or other opioids," he said. "But the reality is that there are still a lot of folks who are addicted and that some of those folks overdose, and that if you have this very safe medicine called naloxone readily available, you can get them rescued, reverse the opioid, and subsequently get them into treatment and into rehab."
Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
Pain Management CME
Physicians, physician assistants, and nurse practitioners can learn about the implications of the U.S. prescription drug overdose epidemic — and what they can do about it — in Pain Medicine: Accidental Lethal Drug Overdoses, a TMA continuing medical education course. The course's objectives include discussion of:
- The number of opioid overdoses in the United States;
- The most commonly prescribed drugs detected in 2011 drug-related fatalities;
- Common dangerous drug cocktails; and
- A patient's risk for substance abuse.
Participants must read the course and complete an online test and course evaluation to receive 1.5 AMA PRA Category 1 Credits™ and 1.5 hours of ethics credits. The course is available through Nov. 15.
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