OPINION: By Roger Crystal, M.D.
The national opioid epidemic poses multifaceted challenges for prescribers. One of the central questions involves the sizable population of patients who experience chronic pain: to what extent should they be co-prescribed the medication naloxone alongside opioid-based medications used to manage their pain? Evidence suggests there are advantages to the co-prescription of naloxone as standard practice for pain patients.
Addressing the needs of chronic pain patients
In the U.S., approximately 100 million adults are affected by non-cancer chronic pain, according to the American Academy of Pain Medicine. Of these, approximately 20 to 30 million receive opioid pain prescriptions, including nearly nine million on a long-term (>30-day) basis. With intense current focus on the potential dangers of opioid overdose, safeguarding these patients against accidental overdose is a must. One viable safeguard is naloxone, which has demonstrated its effectiveness as a life-saving opioid overdose antidote.
Increasingly, the medical community is seeing sense in this approach. According to the American Medical Association, in the first eight weeks of 2017, the number of naloxone prescriptions written by physicians has increased 340 percent compared to the same eight-week period in 2016. The number of physicians prescribing naloxone has also increased 475 percent over the same time period.
Although there is as yet no national policy governing the co-prescription of naloxone, certain states have made it a priority. For example, in June 2016, Gov. Peter Shumlin of Vermont signed several new laws including one requiring prescribers to provide all patients with information and education regarding the safe use, storage and disposal of prescription opioids; it also requires the co-prescribing of naloxone.
Meanwhile, a recent study—funded by the National Institute on Drug Abuse (NIDA) and published in Annals of Internal Medicine—found that patients taking opioids for chronic pain, who were given naloxone in a primary care setting, had 63 percent fewer opioid-related emergency department visits after one year compared to those who did not receive prescriptions for naloxone. This study presented the first large published data regarding co-prescribing naloxone for primary care patients on long-term opioid therapy for pain.
A follow-up study by the same researchers, also funded by NIDA and published in Annals of Family Medicine, evaluated chronic pain patients’ attitudes toward being offered a naloxone prescription. Results showed that 82 percent successfully filled the naloxone prescription and 97 percent believed that patients prescribed opioids for pain should be offered naloxone. Most patients (57 percent) had a positive response to being offered naloxone, and 37 percent reported safer opioid use behaviors after receiving the prescription; there were no harmful behavior changes reported.
The naloxone advantage
This positive reception to naloxone from a segment of the chronic pain patient population dovetails with what is known about the unique advantages of naloxone as a therapy for accidental opioid overdose. Opioid antagonists exist in various delivery forms with demonstrated efficacy, including as nasal sprays.
Prior to the development of the nasal spray approved in November 2015, naloxone was only available in approved forms as injectables—whether a syringe-based injection or autoinjector. In general, people don’t like injecting other people and are afraid of needle-stick injuries even amongst trained and qualified professionals, so there was a motivation to develop a nasal spray version.
These advantages are capable of overcoming any residual stigma due to the prominent media portrayal of naloxone as a mere “rescue therapy” for those who have suffered an illegal opioid overdose. As has been previously reported in National Pain Report, the fact is that patients with chronic pain are overwhelmingly responsible users of medications. Statistics suggest that fewer than three percent of all chronic pain patients those who utilize opioids graduate to abuse of their medications.
The co-prescription of naloxone alongside with opioid pain medications—especially given its availability in convenient intranasal delivery form—appears to be a prudent measure for the well-being of chronic pain patients. The expansion of this policy among prescribers is to be encouraged nationwide.
Roger Crystal, M.D. is Chief Executive Officer of Opiant Pharmaceuticals, Inc., a specialty pharmaceutical company developing pharmacological treatments for substance use, addictive and eating disorders. Opiant developed NARCAN® (naloxone HCI) Nasal Spray, marketed by its partner and licensee, Adapt Pharma.