Ian Ingram, Deputy Managing Editor, MedPage Today
SAN DIEGO — In a 3-month span, 12.7% of patients undergoing medication-assisted treatment (MAT) for opioid use disorder who were given take-home naloxone kits went on to use the opioid blocker on friends and others in the midst of an overdose, researchers said here.
Among the group of 244 high-risk patients, 31 reported using the naloxone kits to successfully reverse 38 overdoses in their community, reported Mikiko Takeda, PharmD, of the University of New Mexico College of Pharmacy in Albuquerque, and colleagues.
Another single-center study looked at barriers that could be limiting emergency department (ED) staff from giving out take-home naloxone kits to those at risk of opioid-related overdose or death.
Both were presented at the American Society of Addiction Medicine (ASAM) annual meeting.
A high number of patients in the study by Takeda’s group had previously overdosed (44.3%), or been witness to someone else overdosing (81.9%). Despite this, prescription logs for these participants revealed that only 15 (6.2%) had ever received a naloxone kit prescription prior to enrollment.
Previous studies have stressed training friends or family members of those at increased overdose risk in the use of naloxone, but only 25 participants (10.3%) had a companion at the time of their visits. The goal of the study was to increase access to naloxone by giving the kits directly to patients on MAT.
Currently the CDC recommends prescribing naloxone to those on chronic opioid therapy receiving a morphine milligram equivalent (MME) dose of 90 or more. The patients in this study had an MME dose of 372, heightening their overdose risk.
“They are taking such higher doses of opioids,” Takeda told MedPage Today. “Naloxone should be mandatory.”
One issue with improving access to take-home kits has been government funding. Recent reports have highlighted cases where maintaining naloxone supplies has proved challenging, with some cities having to ration its use due to financial constraints.
Kaleo — the maker of the auto-injection naloxone used in the study — recently agreed to discount the price of its kits to federal and state governments by 90%, but this comes after a dramatic increase in the list price. According to differing reports, when the auto-injection kits first hit the market in 2014 they were priced at $300; this later increased to $4,500, possibly in anticipation of large-scale government purchases. The price for naloxone inhalers (Narcan) list at about $125 each.
The 244 study participants were from the New Mexico Addiction and Substance Abuse Program, were ages ≥18, and were currently undergoing MAT with methadone, naltrexone, or buprenorphine. Each participant received a demonstration on how to administer naloxone.
The majority of the 38 overdose reversals occurred in friends of the participants (58%), followed by family members (16%) and strangers (13%).
Most of the participants were women (71.3%), and ages 20 to 39 (63.9%). Antidepressants (42.3%) were the most common concomitant medication, followed by anticonvulsants (18.0%), antipsychotics (12%), and benzodiazepines (9.7%).
Carrie Vargo, MD, of Upstate Medical University in Syracuse, New York, nad colleagues examined electronic health record data, and found that 5,472 patients who came through the ED the previous year were possible candidates for take-home naloxone. Even among the 434 patients at the highest risk — those who came in for opioid poisoning or opioid-related adverse events — only about 80 were given take-home kits.
The other opportunities for distributing take-home kits were seen in 1,746 patients who came through the ED with issues unrelated to opioids (but whose charts listed a history of opioid or intravenous drug abuse), and in 3,292 individuals with a history of chronic pain disorders, many of whom were regularly prescribed opioids.
“We have all these kits available, and nobody is handing them out,” Vargo said. “The biggest barrier was that they just didn’t know it was available.” And some of those who knew of the program believed only pharmacists could dispense the kits, she added. The naloxone kits were supplied for free by the New York State Department of Health.
Originally, only those highest-risk patients were seen as candidates for the naloxone kits. “The unfortunate thing is those are the most difficult people to treat cause they don’t want to be there,” she said. “If we’re lucky, we can grab a family member that’s at the bedside and do the training there.”
To assess the barriers to distribution, Vargo’s group conducted an anonymous web-based survey of 120 ED members, the majority of whom were physicians (n=53) and nurses (n=40).
Only six respondents reported that they frequently handed out the naloxone nasal spray kits, with 74 saying they had never given out a take-home kit to someone who had overdosed or was a high-risk patients. Despite that, 73% reported that they would be willing to hand out these kits to high-risk users of opioids or their loved ones.
The survey revealed disagreement among staff as to whether increased naloxone access encourages risky opioid behavior, with 17 of 18 respondents saying they were completely unwilling to hand out naloxone for this reason. Among registered nurses surveyed, 62.5% agreed with this sentiment to some degree. More research is needed to understand why this might be the case among nurses, according to the authors.
Respondents also felt that training patients would take too long. “It actually doesn’t once you train everybody the same way and have it protocolized,” said Vargo.
Following the survey, ED staff were given training via a 20-minute PowerPoint presentation. “We have over 100 nurses in our department that now are trained,” she said. “The nursing staff has really championed it.” Those given the take-home kits can be trained in 3 minutes, she said.
Evidence that naloxone reduces mortality was cited by those surveyed as a factor that would improve distribution of the take-home kits. One recent study that looked at patients who had naloxone administered from emergency services found that 85% were still alive 1 year later — in 40% of the patients that died, it was later on in the day that they were resuscitated.
Other factors were if it became common practice and if there was encouragement from ED leaders.