New research has found that when naloxone is widely available to patients who are prescribed opioids, hundreds of overdose deaths can be prevented. But a deeper understanding of the medicine and its use is required from pharmacists.
Most opioid-related deaths in Australia are due to prescription opioids, yet the focus of naloxone supply is geared towards illicit opioid use, say the authors of a new modelling study into the cost and impact of distributing naloxone to people who are prescribed opioids.
When 90% of patients prescribed 50 mg oral morphine equivalents (OME) or above receive free naloxone, the research found a staggering 650 lives over a 10-year period could be saved.
The researchers evaluated five scenarios to reach this conclusion. One was to retain the status quo, where naloxone is not readily prescribed or dispensed to people prescribed opioids for pain. There were also four scale-up scenarios, with targets from 30–90%, considering moderate and high opioid doses.
The 30% range included a target of people who were prescribed a moderate dose of 50 mg OME and above, and another that focused on higher doses of 100 mg OME and above, said lead researcher Associate Professor Suzanne Nielsen MPS, Deputy Director of the Monash Addiction Research Centre (MARC) in Melbourne.
‘Then we had two scenarios where we used the same dose cut-offs, 50 mg and 100 mg OME, but we scaled up to 90% of people,’ she told Australian Pharmacist.
While there are cost implications in providing free naloxone to the large number of Australians prescribed opioids every year, the study found the ‘cost per life saved’ was around $44,000 when scaled up to 90% of patients on 50 mg OME.
‘This is considered to be incredibly cost-effective as an intervention,’ A/Prof Nielsen said.
‘We don’t need complicated screening to look for people with specific risk factors, other than if you’re on a moderate to high dose of opioids, you should be supplied with naloxone.’
Reducing stigma around naloxone
Pharmacists have a vital role to play in educating patients and those close to them about the signs of opioid toxicity and what to do if this occurs, said Advanced Practice Pharmacist Dr Jacinta Johnson FPS, who spoke about naloxone for opioid toxicity at PSA21.
‘This includes a discussion around the purpose and availability of take home naloxone to minimise harm if toxicity does occur,’ she said.
The problem is, pharmacists may assume naloxone is only for injecting drug users, A/Prof Nielsen said.
They might also be concerned that providing naloxone could encourage patients to use their prescribed opioids irresponsibly.
But a recent systematic review led by A/Prof Nielsen and MD candidate Wai Chung Tse found that those assumptions are not supported by evidence.
‘We saw reduced substance use among people who are prescribed opioids and [supplied] with naloxone, and there’s a lower likelihood that they’ll have an overdose,’ A/Prof Nielsen said.
This is likely due to patient education about the risk factors of opioids where naloxone is supplied, as most people don’t have high awareness of opioid toxicity.
‘Having those conversations around naloxone is a key opportunity to make sure people understand the [adverse] effects of opioids, and are empowered to be able to do something about it,’ she said.
Pharmacists should also consider broaching the topic with family members or carers, who would administer naloxone when needed.
It’s not uncommon to hear accounts from coronial inquests of other people being in the home when a person dies from prescription opioid toxicity, A/Prof Nielsen said.
‘But [when] they don’t recognise the symptoms, [for example] if they just thought the person was snoring, they don’t intervene,’ she added.
Counselling tips for naloxone use
When discussing naloxone with patients, Dr Johnson often starts by explaining that all medicines can have adverse effects. But as opioids are strong pain medicines, those adverse effects can be serious.
‘I’ll then discuss what those [adverse] effects can be, including the effects on breathing,’ she said.
‘[I’ll say], “Because of the serious nature of the possible [adverse] effects, I recommend having the antidote, called naloxone, on hand to reverse any toxicity if it does occur”.’
After discussing the signs of opioid toxicity, Dr Johnson suggests pharmacists run through the importance of calling an ambulance if these signs occur and then introduce naloxone into the conversation.
‘Pharmacists should cover how naloxone works, how to administer a dose using the particular formulation being supplied, how to monitor the effect of naloxone and when to re-dose, if needed,’ she said.
To upskill pharmacists in naloxone and how to discuss the treatment, the MARC team recently co-designed resources, including sample phrases and animations, with chronic pain patients.
According to A/Prof Nielsen, using the right language is vital.
‘We know that people who are prescribed opioids sometimes don’t respond when they hear the word overdose, [because] they think you’re talking about illicit drug use, or intentional overdose or suicide,’ she said.
It’s important to get the message out that severe adverse effects from opioids can occur with a prescribed dose, due to factors such as medicine interactions or a change in physiology.
Dr Johnson suggested the Penington Institute’s free resource for pharmacists, which offers communication tips and phrase suggestions for discussing naloxone in an open way with patients.
Pharmacists in South Australia, Western Australia and New South Wales can provide naloxone for free, and receive remuneration for supplying it, through the Commonwealth Take-home naloxone pilot, recently extended until the end of June 2022.
In other states or non-participating pharmacies, however, patients have to pay between $30–$50 to buy naloxone over the counter, A/Prof Nielsen said.
This leads to cost and equity issues in the supply of the medicine, said PSA General Manager Policy and Engagement Chris Campbell.
As a result, PSA is advocating for naloxone to be subsidised by the Pharmaceutical Benefits Scheme (PBS) as a Schedule 3 medicine.
While currently available with a prescription under the PBS, naloxone is not commonly co-prescribed with opioids, Mr Campbell said.
PSA National President A/Prof Chris Freeman welcomed the Commonwealth pilot, but said it does not go far enough.
‘We need to improve access to this life-saving medicine through all pharmacies across all jurisdictions, by making it the first pharmacist-initiated and supplied PBS item. In doing so, we can decrease the amount of deaths from overdose,’ he said.
‘If you can improve the ubiquity of access and an awareness of [naloxone] availability, it would be much like ensuring someone with anaphylaxis always has an EpiPen close by,’ Mr Campbell said.
‘We need … a multifactorial response all the way from the ease of access, reducing stigma, and education for prescribers and pharmacists.’