In April 2018, the US Surgeon General recognized the gravity of the US opioid epidemic and issued a rare public health advisory calling for increased availability of naloxone. This policy explicitly acknowledges that naloxone—a rescue medication that temporarily reverses the effects of an opioid overdose—does not cure opioid addiction. However, by preventing immediate harms such as death, naloxone use offers the survivor an opportunity to enter treatment when ready.
Unfortunately, national implementation of a policy aimed to enhance access to naloxone faces many practical barriers, including identifying those most likely to benefit, deciding how and where to distribute the medication, and ensuring affordability. Naloxone prices have increased markedly over the past few years and range between $20 for a generic vial to $4,500 for an easy to use auto injector. Separate from drug acquisition costs, high consumer out-of-pocket costs required by many health plans may hinder access for those with insurance coverage. A program that targets naloxone to those most likely to benefit—instead of a broad population-based implementation—is most likely to be of highest value.
Identifying Those at High Risk and Where to Reach Them
Targeted distribution would focus on getting naloxone into the hands of the populations that need it most. Available evidence identifies two distinct groups at highest risk of overdose: 1) individuals who receive prescription opioids and regularly interact with health care systems, and 2) those who use non-prescribed opioids for non-medical use (e.g. heroin, illicitly manufactured fentanyl). In addition, an important third population—those who are likely to witness an overdose—must also be included. The three populations require distribution approaches tailored to their individual needs.
Prescription Opioid Users
For individuals prescribed prescription opioids, there is robust evidence to create “risk scores” to stratify patients, including a tool to predict overdose over two years, a time frame chosen based on the shelf life of naloxone. Risk factors include substance use disorders, high prescribed dosage, mental health comorbidities, and concurrent use of benzodiazepine or anti-depressants. Since these patients interact regularly with the health care system, electronic medical records could be used to identify at-risk individuals. Clinical support tools could then alert clinicians to prescribe naloxone concomitantly with other medical prescriptions to allow more convenient access for the patient.
Illegal Opioid Users
It is estimated that anywhere between 13-69 percent of people with illegal opioid use will experience an overdose, compared to less than 2 percent of long-term prescription opioid users. This high overdose rate suggests that universal naloxone distribution to these at-risk individuals is an appropriate strategy. The challenge, therefore, in this high-risk cohort is not determining whether naloxone is warranted, but instead identifying cohort members and ensuring that naloxone is both accessible and affordable to them.
Finding a venue that offers naloxone without perpetuating stigma is difficult. While pharmacies may offer a convenient location, evidence suggests that consumers often feel stigmatized when asking for naloxone from pharmacists, and pharmacists also feel uncomfortable initiating such discussions. In fact, many pharmacies in cities and states that have standing order policies for naloxone (i.e., it can be obtained at a pharmacy without a prescription) don’t adequately stock the medication.
Without thoughtful processes to reduce stigma, pharmacy distribution of naloxone to users of illegal opioids will remain limited. Needle exchange programs, emergency rooms, and other treatment programs where patients are treated for overdoses and other drug use-related consequences are high yield venues where naloxone distribution may be more person-centered.
Third Party Witnesses of Overdose
Americans from all walks of life are increasingly likely to witness an opioid overdose, without being personally at risk. Nationally, law enforcement officers, as first responders, have proven to be a critical group for layperson administration. In addition, non-professional bystanders such as caregivers, family members, and friends who regularly interact with high-risk individuals can reduce fatal overdoses by naloxone administration. In our region, non-medical staff at community organizations that serve populations with higher rates of opioid use disorders, such as shelters, have sought training after having had overdoses occur on their premises. Additional settings that attract at-risk groups are also likely to be high value sites for naloxone distribution.
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