Prescribe to Prevent

• Can I prescribe naloxone to a caregiver not at risk for overdose?

You cannot prescribe a medication to someone for whom it is not indicated (except in Washington, in Illinois, in New York and Massachusetts- click on the states to see specific legislation, in Illinois, prescribers wishing to write a prescription for a third party (caregiver) must register). Possession of naloxone prescribed to others is technically not authorized. However, in practice many prescription drugs are commonly held by caregivers. If you are a provider of both the caregiver and the person at risk of overdose, the prescription should be written for the person potentially at risk for overdose.

• Who should be educated in the use of a naloxone rescue kit? How should they be identified?

Primary care, urgent care and pain patients that meet these inclusion criteria should receive training and a naloxone prescription. These criteria were the ones approved by the North Carolina Medical Board.

Patients presenting in the emergency department with opioid poisoning or who exhibit risk on the Drug Abuse Screening Test (DAST-10) or other screening test.

Patients upon entry into or out of substance abuse treatment, at the time or positive toxicology screening, and upon request.

• Who should provide the education? How long does it take?

Overdose prevention education can be done by handout, video or in person by the prescriber, support staff or pharmacist. Depending on the number of questions, education can take between 3 and 15 minutes.

• How should providers/staff be trained?

Providers/staff can orient themselves by way of a review of the relevant literature or contact us for sample training materials that can be presented during regular staff training.

• What about liabilities and risk following injection or naloxone administration errors?

Naloxone is a relatively safe medication that is generally associated with fewer risks than other commonly used injectable rescue medications such as epinephrine for anaphylactic shock and glucagon for hypoglycemia. We are aware of no case in which a provider of naloxone has been subjected to a malpractice case or professional discipline. For a complete discussion of legal issues, see Medico-Legal Resources.

• What are the results of other programs like this/who else is doing this work?

Take home naloxone is being implemented successfully in a variety of contexts. Project Lazarus and Community Care of North Carolina are rolling out the CHRONIC PAIN PROJECT, with initial results available HERE. A federally-funded research study is underway in Rhode Island to provide overdose prevention education and naloxone to incarcerated people upon release, with an educational video specifically for this population available HERE. CLICK HERE for a presentation about overdose prevention and naloxone at methadone maintenance treatment programs. Naloxone is being made available to people through harm reduction programs. Here are articles on that work in CHICAGO, BALTIMORE, BOSTON, SAN FRANSCISCO, and PITTSBURGH.

• Why is prescribing naloxone superior to basic life support and calling 911?

Prescribing naloxone should be done in addition to discussing rescue breathing and calling 911. Including naloxone in comprehensive overdose education is important because timely naloxone administration may shorten the time that the overdose victim experiences oxygen deprivation, just a few minutes after which hypoxic brain injury begins to occur.

Further, current Hands-Only CPR guidelines for lay responders are focused on sudden collapse due to heart attack and do not include rescue breathing. These guidelines do not overtly highlight the importance of rescue breathing during opioid overdose and drowning. Patients who have received CPR recent training may have been encouraged to discontinue rescue breathing universally, as opposed to the more appropriate context of only during a heart attack.

• How much does the naloxone cost? Who is paying for the naloxone?

Intra-muscularly administered naloxone costs under $10 for a complete rescue kit (Naloxone HCl 0.4 mg/mL 1 x 10 mL as one fliptop vial (NDC 0409-1219-01) OR 2 x 1mL single dose vials (NDC 0409-1215-01) + 2 x Intramuscular (IM) syringe, 23 G, 3cc, 1 inch).

Intra-nasally administered naloxone costs approximately $25-35 for a complete rescue kit (2 x 2 mL as pre-filled Luer-Lock needless syringe (NDC 0548-3369-00) + 2 x Intranasal Mucosal Atomizing Device (MAD 300).

Most insurance, Medicaid and Medicare will pay for naloxone, but coverage varies by state. The nasal adapter is not covered by insurance. Compiling a list of insurance plans in your area that will cover naloxone and collaborating with a pharmacist will be helpful. Because naloxone is not an expensive medication, even patients whose insurance will not cover the medicine may be willing to pay for naloxone. Advocates in some locations have been successful in persuading insurers to cover the cost of naloxone or have it added to local ADAP (AIDS Drug Assistance Program) formularies.

• How can I bill for the training time?

Screening Brief Intervention Referral to Treatment (SBIRT) can be used to bill time for counseling a patient. Complete the DAST-10 and counsel the patient on how to recognize overdose and how to administer naloxone, using the following sheets. Refer to drug treatment program if appropriate. For pain patients, the DAST-10 may not be appropriate. Instead, for new pain patients consider using the Screener and Opioid Assessment for Patients with Pain (SOAPP), and for patients already stably on opioid therapy, consider administering the Current Opioid Misuse Measure (COMM).

• What is the liability of prescribing naloxone? What if they use it on someone else (medication is not prescribed to them/ use is not as directed)?

Prescribing naloxone to opioid users is fully consistent with state and federal laws regulating drug prescribing. CLICK HERE for a more detailed state by state medico-legal analysis.

Patients receiving a naloxone prescription should receive verbal and written instructions on how and when to use this drug. Prescribers/staff should not instruct patients to administer naloxone to persons who do not have a valid prescription for the drug; however, both prescribers and patients can educate a potential bystander how to administer the medication to the patient during an overdose emergency.