Frequently Asked Questions About Opioid Overdose and Naloxone for Providers
What is naloxone?
Naloxone is a fast-acting opioid antagonist that can quickly reverse the effects of an opioid overdose. It can be administered intramuscularly or intranasally.
Is naloxone safe?
- Naloxone is safe and easy to use.
- It can be safely administered to pregnant women and children.
- It has no effect on patients who have not used opioids.
- The main adverse effect associated with its use is the precipitation of acute opioid withdrawal, which is not fatal
What is a Standing Order prescription for naloxone
The Baltimore City Health Commissioner Dr. Wen’s Standing Order for naloxone is essentially a city-wide prescription for naloxone that allows any pharmacist in Baltimore to dispense naloxone to a patient. Under the Standing Order prescription and state law, naloxone may be dispensed to any person who is believed to be at risk of experiencing an opioid overdose, or who is in a position to assist an individual at risk of experiencing an opioid overdose, regardless of training.
Who is covered by Baltimore City Health Commissioner Dr. Leana Wen’s Standing Order for naloxone?
Now that there is no training requirement for patients to receive naloxone, how will patients learn to recognize and respond to an opioid overdose with naloxone?
The Baltimore City Health Department’s Community Risk Reduction Services and other Overdose Response Programs in Baltimore City will continue to offer training for anyone who wants to learn to use naloxone. Pharmacists and prescribers also have significant roles to play in ensuring patients are prepared to use the medication to save a life from overdose. Patients can view a short training video at www.dontdie.org. Contact Mark O’Brien at firstname.lastname@example.org if you are interested in downloading a copy of this video.
What formulations of naloxone are covered by the Standing Order prescription?
- Evzio® (Naloxone Hydrochloride injection) Auto-Injector
- Narcan® (Naloxone Hydrochloride) Nasal Spray
- 2 mg/2 mL Luer-lock injection dispensed with intranasal mucosal atomizer device.
Are providers protected from liability when they dispense or administer naloxone?
Under state law, any health professional who administers, prescribes, or dispenses naloxone may not be subject to any disciplinary action solely for the act of prescribing or dispensing naloxone. Similarly, individuals who administer naloxone to an individual who is or in good faith is believed to be experiencing an opioid overdose are immune to liability from their actions.
When should I prescribe naloxone or recommend that a patient receive it under the Standing Order?
According to the CDC guidelines for prescribing opioids for chronic pain, naloxone should be offered to patients when risk factors are present. In particular, the CDC recommends naloxone for those patients with a history of overdose, a history of substance use disorder, those taking benzodiazepines, patients at risk for returning to a high dose to which they are no longer tolerant (such as after abstinence or release from incarceration), and patients taking doses >50 mg MED per day.
The Baltimore City Health Department recommends that naloxone be co-prescribed with every opioid prescription and that pharmacists should advise patients to obtain naloxone under the Standing Order if they are filling a prescription for opioids.
How are pharmacies reimbursed for naloxone?
Naloxone reimbursement may vary by insurance provider. Under state law, insurance providers may implement prior authorization requirements for naloxone but only if there is at least one formulation that does not require a prior authorization.
For those patients inquiring about Evzio, the manufacturer currently has pricing assistance available on their website, www.evzio.com, and they maintain a hotline for pharmacists and patients, at 877-438-9463.
Naloxone formulations that fall under the Maryland Preferred Drug List are available with a $1 co-pay. The 2017 list includes ]Narcan® Nasal Spray and 2 mg/2 mL Luer-lock injection dispensed with intranasal mucosal atomizer device.
Evzio auto-injector will require prior authorization for Medicaid coverage.
What factors make patients more likely to experience an opioid overdose?
Opioid use characteristics
- Opioid doses > 50 mg morphine equivalent dose (MED) per day
- Long-acting and extended release formulations
- May be at greater risk within first two weeks of starting long-acting/extended-release opioids
- Long-term opioid use (>3 months)
- Rotation from one opioid to another
- Being started on methadone or buprenorphine
- Concomitant benzodiazepine use
- Medications or substance with sedative properties
- Age > 65
- Previous overdose events
- Substance abuse, including alcohol
- Depression or anxiety disorders
- Respiratory disorders and sleep-disordered breathing (such as sleep apnea)
- Renal and/or hepatic impairment
- Recent opioid detoxification and/or participation in abstinence program
- Recent release from incarceration with a history of opioid use disorder
- Living in remote locations where emergency help may not be readily available
What happens during an opioid overdose?
During an overdose, a person’s body becomes so relaxed that they stop breathing sufficiently to provide the oxygen their body needs. Individuals who are experiencing an overdose may exhibit several characteristic signs, including:
- Unresponsiveness to verbal cues or sternal rub
- Fingertips or lips turning blue or gray
- Breathing that is slow, shallow or stops
- A gurgling or snoring sound
- Pinpoint pupils