Primary Care Patient Experience with Naloxone Prescription

The valuable findings in this very straightforward study by Behar and colleagues offers encouragement that patients welcome a co-prescription of naloxone. It is important to do so, and should be done, however it adds to the intensity of safety monitoring for this dangerous class of analgesics that has little supportive data for long term use in chronic non-cancer related pain. No other class of medication requires a Risk Assessment, periodic Prescription Drug Monitoring investigation, Urine Drug Screen, Pain Management Agreement and now an antidote. If that's not enough motivation to abandon this class first line, then keep reading.

I doubt any of us would co-prescribe Digibind when adding digoxin to diltiazem, amiodarone and atorvastatin. We would simply deem this "Not Safe".

Despite the broad efforts of communities, law enforcement and pharmacies to make naloxone more readily available and raise awareness to the dangers of opioid misuse, we are not getting the message that our prescribing habits are reducing the population. A study published this year revealed a pathetic response toward opioid overdoses. 2848 non-fatal overdoses were documented in all 50 states. Of those, 91% were given more opioids over the next year (median f/u 299 days)(1). Naloxone should be prescribed after an overdose not the same medication that just nearly ended the patient's life.

We've become way too comfortable in prescribing opiates. The FDA mandated the manufacturers of LA/ER opioids provide education to prescribers, termed "Risk Evaluation and Mitigation Strategy (REMS) for Extended- Release and Long-Acting Opioids." After completing my own module, I surprisingly felt a bit more at ease with this class and frankly a bit disturbed by it. That's not good. Fortunately, I only have a handful of patients on short acting opioids and intend to shorten that list before I hear the tolerance induced request of "My friend's OxyContin works great, can I have a script doc?".

If we are co-prescribing an antidote for a class of medication that has killed more Americans than any other, perhaps we should simply work hard not to prescribe opioids when safer analgesics and behavioral modalities exist.

"First Do No Harm" is our first duty. We need to apply this to all aspects of treatment, exemplifying it to our next generation of physicians.

1. Ann Intern Med. 2016;164(1):1-9. doi:10.7326/M15-0038

Competing interests: None declared