New guidelines advise doctors to co-prescribe naloxone with opioids to high-risk patients

A coctor writing a prescription
New guidance advises physicians to prescribe an opioid antidote to patients at risk of overdosing. (Getty/18percentgrey)

Physicians should consider writing a prescription for naloxone along with prescriptions for opioids for high-risk patients, especially those at danger of overdosing, according to new government guidelines (PDF) released Wednesday.

The Department of Health and Human Services (HHS) guidance expands upon previously released guidelines from the Centers for Disease Control and Prevention.

Given the country’s opioid epidemic, doctors need to discuss overdose dangers with patients, Adm. Brett P. Giroir, M.D., assistant secretary for health and senior adviser for opioid policy, said in an announcement about the new guidelines.

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2019 Drug Pricing and Reimbursement Stakeholder Summit

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“It’s critically important that healthcare providers and patients discuss the risks of opioids and how naloxone should be used in the event of an overdose,” Giroir said. “Co-prescribing naloxone when a patient is considered to be at high risk of an overdose is an essential element of our national effort to reduce overdose deaths and should be practiced widely.”

RELATED: Nation’s top doctor wants the overdose antidote widely on hand. Is that feasible?

The guidance recommends that clinicians prescribe or co-prescribe naloxone to patients at risk of overdose, including, but not limited to, patients who are on relatively high doses of opioids, who take other medications that enhance opioid complications or have underlying health conditions.

It's a measure that has won support in the medical community. Prescribing naloxone does appear to save lives and more doctors are prescribing it to patients, Alan Schwartzstein, M.D., a family physician who practices in Oregon, Wisconsin, said in an interview with FierceHealthcare.

Alan Schwartzstein
Alan Schwartzstein, M.D. (AAFP)

But doctors would also like to see barriers to prescribing the potentially lifesaving drug removed, said Schwartzstein, a speaker of the American Academy of Family Physicians’ Congress of Delegates, the group’s policymaking body. Some insurers require prior authorization before approving the drug for patients, and the cost can be high, he added. Further, it is important that it remain up to doctors to decide which patients can benefit from the drug, he said.

 
The guidance provides some specifics to help doctors determine which patients they should “strongly consider” prescribing naloxone, including:
  • Those receiving opioids at a dosage of 50 morphine milligram equivalents per day or greater
     
  • Those with respiratory conditions such as chronic obstructive pulmonary disease or obstructive sleep apnea (regardless of opioid dose)
     
  • Those who have been prescribed benzodiazepines (regardless of opioid dose)
     
  • Those who have a nonopioid substance use disorder, report excessive alcohol use or have a mental health disorder (regardless of opioid dose)

The guidance says patients at high risk for experiencing or responding to an opioid overdose include those:

  • Using heroin or illicit synthetic opioids or misusing prescription opioids
     
  • Using other illicit drugs such as stimulants, including methamphetamine and cocaine, which could potentially be contaminated with illicit synthetic opioids such as fentanyl
     
  • Receiving treatment for opioid use disorder, including medication-assisted treatment with methadone, buprenorphine or naltrexone
     
  • With a history of opioid misuse that were recently released from incarceration or other controlled settings where tolerance to opioids has been lost.

Congressman John Sarbanes, a Democrat from Maryland who authored a bill to fight the opioid epidemic, praised the release of the new guidelines. “These new HHS guidelines are an important and encouraging step forward in our fight against the opioid epidemic,” he said in an announcement. “By getting more affordable and easy-to-use overdose reversal drugs into the hands of patients and communities across the country, we can save countless lives.”

In April, U.S. Surgeon General Jerome M. Adams, M.D., issued a public health advisory urging more people, including family, friends and those personally at risk for opioid overdose, to carry naloxone.

However, there’s a catch. Recent news reports say that some people, including medical professionals, are being denied life insurance because naloxone appears on their medication list and is interpreted as an indication they use drugs.

That prompted one U.S. senator, Ed Markey of Massachusetts, to ask for details about those life insurance denials, according to CommonHealth. He sent a letter asking two national organizations that deal with life insurance for details about companies denying coverage to applicants who carry naloxone for emergencies. NPR reported that a registered nurse who works in an addiction treatment program at Boston Medical Center was denied coverage from two different insurers because she carries the drug.

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