Over­dose an­ti­dote should ac­com­pany pain pre­scrip­tions, S.F. re­port urges

San Francisco Chronicle - - FRONT PAGE - By Erin All­day

A drug that is ef­fec­tive at re­vers­ing heroin over­doses isn’t just for street ad­dicts — it should be rou­tinely dis­trib­uted to peo­ple tak­ing pre­scrip­tion pain med­i­ca­tions who may not ap­pre­ci­ate their risk of ac­ci­den­tal death, San Fran­cisco pub­lic health of­fi­cials said in a study re­leased Mon­day.

Doctors should con­sider reg­u­larly pre­scrib­ing nalox­one — a drug given by in­jec­tion or nasal spray to coun­ter­act opi­oid over­doses — along­side nar­cotic pain med­i­ca­tions, the study’s au­thors said.

Nalox­one, of­ten sold un­der the brand name Nar­can, has be­come in­creas­ingly pop­u­lar as a way to re­verse heroin over­doses among street users. In San Fran­cisco, nalox­one has been widely dis­trib­uted for more than 15 years to users and their friends and rel­a­tives, a prac­tice that has dra­mat­i­cally cut heroin over­dose

deaths — from 120 in 2000 to 30 in 2014.

But nalox­one isn’t widely dis­trib­uted to the larger pop­u­la­tion of pre­scrip­tion drug users, who now make up more than 75 per­cent of all over­dose deaths in San Fran­cisco.

High-pro­file deaths

Opi­oid over­doses, most of them in­volv­ing pre­scrip­tion drugs, killed a record 28,000 peo­ple in the United States in 2014. High-pro­file deaths, like that of Prince this year, have un­der­scored the need both to pre­vent ad­dic­tion and to quickly treat peo­ple who have over­dosed.

“This study re­ally does show that nalox­one has a sub­stan­tial role to play in manag­ing the opi­oid epi­demic,” said Dr. Phillip Cof­fin, di­rec­tor of sub­stance use re­search at the San Fran­cisco Depart­ment of Pub­lic Health and lead au­thor of the pa­per, pub­lished in the An­nals of In­ter­nal Medicine. “It’s not the an­swer to all our prob­lems, but it’s an im­por­tant tool to pre­vent mor­tal­ity.”

Peo­ple on nar­cotic pain med­i­ca­tions who have pre­vi­ously been ad­dicted to drugs or al­co­hol, or who have over­dosed be­fore, are es­pe­cially at risk and should al­ways be of­fered nalox­one, Cof­fin and other pain ex­perts say. But even peo­ple who wouldn’t con­sider them­selves at risk could prob­a­bly ben­e­fit from hav­ing nalox­one around in case of ac­ci­den­tal over­dose, Cof­fin said.

Deadly glass of wine

Some peo­ple may not re­al­ize, for ex­am­ple, that just one glass of wine on top of their Vi­codin could cause an over­dose, or that a new pre­scrip­tion for a sleep aid or mus­cle re­lax­ant could cre­ate a deadly cock­tail.

Symp­toms of over­dose in­clude stopped or slowed breath­ing and loss of con­scious­ness. Nalox­one will usu­ally re­vive some­one af­ter one or two min­utes, though some peo­ple may need a sec­ond dose. Any­one who is treated for over­dose should be seen by a doc­tor right away.

Cof­fin’s re­search in­volved six San Fran­cisco pub­lic health clin­ics, where doctors and other care providers were of­fered train­ing for pre­scrib­ing nalox­one to pa­tients tak­ing opi­oid pain med­i­ca­tions. From Fe­bru­ary 2013 to April 2014, 759 pa­tients — a lit­tle over a third of all peo­ple pre­scribed opioids at those clin­ics — were given nalox­one pre­scrip­tions.

ER vis­its dropped

The study found that over the fol­low­ing year, pa­tients with nalox­one pre­scrip­tions had about 50 per­cent fewer vis­its to an emer­gency room for opi­oid-re­lated prob­lems — in­clud­ing over­doses, falls or re­quests for more pain med­i­ca­tions — com­pared with those who didn’t get a pre­scrip­tion. The study did not look at over­dose deaths be­cause there weren’t enough peo­ple in­volved to draw sta­tis­ti­cally sig­nif­i­cant con­clu­sions.

Some health care providers have won­dered whether pre­scrib­ing nalox­one could lead to an in­creased use of opioids, but the San Fran­cisco re­searchers found no ev­i­dence of it. In­stead, Cof­fin and other pain and ad­dic­tion ex­perts be­lieve that pre­scrib­ing an over­dose an­ti­dote may make pa­tients more in­clined to be cau­tious about their opi­oid use.

“If I’m telling you this med­i­ca­tion is dan­ger­ous and I’m also pre­scrib­ing you the an­ti­dote to this med­i­ca­tion — that’s stark in­for­ma­tion,” Cof­fin said. “It makes the mes­sag­ing stick.”

No pre­scrip­tion needed

The U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion rec­om­mends that doctors con­sider nalox­one pre­scrip­tions for some pa­tients us­ing opioids — mostly those con­sid­ered to be at high risk of over­dos­ing. Nalox­one is also avail­able with­out pre­scrip­tion from phar­ma­cies in Cal­i­for­nia and sev­eral other states.

Kaiser Per­ma­nente en­cour­ages its doctors to pre­scribe it to pa­tients who are on pro­longed, high-dose pain man­age­ment reg­i­mens. Pa­tients can also pick up nalox­one at a Kaiser phar­macy with­out their doc­tor know­ing they’ve asked for it.

Sut­ter Health, too, has been push­ing out more nalox­one pre­scrip­tions on pa­tients with a his­tory of opi­oid abuse, said Dr. Josh Kay­man, med­i­cal di­rec­tor of Sut­ter’s adult sub­stance abuse in­pa­tient pro­gram in Oak­land.

At New Leaf Treat­ment Cen­ter in Lafayette, staffers be­gan hand­ing out nalox­one to clients as well as friends and fam­ily late last year be­cause of the fre­quency of over­doses among opi­oid users, said Dr. Alex Stal­cup, med­i­cal di­rec­tor. They’ve dis­trib­uted hun­dreds of nalox­one kits, Stal­cup said, and so far they know of six peo­ple who took it af­ter over­dos­ing.

“Peo­ple are happy to have it,” Stal­cup said. “They know they’re danc­ing on a dime, and it’s re­ally good to know — here is some­thing that you can do.”

Mel Evans / Associated Press 2014

Nalox­one, also known by the brand name Nar­can, re­verses the deadly ef­fects of an over­dose.

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