We know more now about the risk factors and patients who may be good candidates for naloxone. These would include patients on higher doses of opioids, patients with complicated comorbidities like renal or hepatic disease, sleep apnea, and most obviously, those with active substance abuse, or a substance abuse history. Other considerations would include patients with liver hepatic dysfunction, and concomitant use of benzodiazepines.
One commercially available naloxone product is an auto-injector that administers the medication through the intramuscular or the subcutaneous route. There is also a device that affords intranasal administration. Some problems with the intranasal option would be patients who have any sort of intranasal abnormality, such as nasal structure, nose bleeding, excessive mucus that would impair naloxone absorbtion. Then there is some variability in the time to response with intranasal. It can be about the same or two minutes longer compared to intramuscular, which is about six to eight minutes.
Naloxone was specifically developed to be administered by the intramuscular route. We have some better numbers on response time and fewer limits or contraindications with that route. But for patients who are needle-avers, or shoes family members aren’t comfortable manipulating needles, of in cases of concern for transmission of blood-borne pathogens, one would potentially consider the intranasal naloxone.
The landscape for naloxone availability is changing and specific by state. Some states or communities are allowing you to go to the pharmacy and there is increasing access through other programs. Historically, naloxone kits have been dispensed to patients with heroin addiction. This is a new forefront dispensing it to patients on chronic opioid therapy. There have been cases of naloxone shortages, and cases where naloxone prices have significantly increased because of those shortages.
The clinician’s conversation about naloxone--the signs and symptoms of opioid overdose--should include the spouse or caregiver or family member, because they’re going to be the ones actually calling 911 and administering the medication and potentially saving the patient’s life. That conversation is also a good time to revisit chronic opioid therapy in general. What are the patient’s goals? Have opioids helped them achieve those goals? Are they having any kinds of side effects; those types of things? Good prescribing practice involves weighing the risks and benefits of continuing opioid therapy with each patient and assessing their activity, their analgesia side effects, and their aberrant behavior in terms of opioids. Giving someone naloxone doesn’t replace good opioid prescribing practices.