Coffin et al6 conducted a 2-year study of naloxone and opioid co-prescribing for high-risk primary care patients receiving long-term opioid pain therapy in San Francisco, California. The numbers of opioid-related emergency department visits at 6 months and 1 year were found to be lower among the patients who received naloxone than in the patients who did not receive naloxone. At the US Army military installation at Fort Bragg, North Carolina, the number of emergency department visits for opioid overdose declined from eight to zero per month after naloxone co-prescribing started.6,23 In North Carolina, Project Lazarus partnered a community-based prevention program with local clinicians in which naloxone was offered to suspected opioid abusers and to patients undergoing opioid treatment for pain who were considered to be at high risk for opioid overdose as part of their regular medical care. As a result of the co-prescribing and enhanced education for prescribers and laypersons, the number of opioid-associated deaths decreased by 50% in a single year.4,23 Therefore, researchers recommend that naloxone be co-prescribed to primary care patients being treated with opioids for pain, with emphasis placed on those who have established risk factors, including receiving higher doses of opioids and having a record of opioid-related emergency department visits in the past.6

The number of community-based organizations providing naloxone kits to individuals is increasing. Nonetheless, in 2013, there were 20 states that did not have an organization providing naloxone kits to laypersons, and nine states had fewer than one layperson per 100,000 who had received a naloxone kit. Of the 29 states with marginal or no layperson access to overdose rescue kits, 11 had overdose death rates higher than the national median, underscoring the need for naloxone and opioid co-prescribing in primary care clinics.8

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In response to the idea that clinicians’ fear of offending patients creates a barrier to naloxone prescribing in primary care, Behar et al evaluated the experience of patients undergoing opioid treatment for chronic pain with naloxone and their reactions to the offer of a naloxone prescription.23 Overall, offers of naloxone prescriptions were acceptable to primary care patients receiving opioids. Most responded positively and believed that naloxone was appropriate. Furthermore, 60% of the patients had never heard of naloxone before the intervention, and more than one-third noted positive behavioral changes after receiving naloxone, with no negative behavioral changes. Behar et al propose that primary care clinicians may serve a population that community naloxone distribution does not reach, thus aiding a reduction in the morbidity and mortality of opioid poisoning.

Following the recommendations of the US Substance Abuse and Mental Health Services Administration, the American College of Emergency Physicians (ACEP) has issued guidelines for prescribing naloxone as an early antidote to at-risk patients in the following situations7:

  • Discharged from an emergency department after opioid overdose
  • Prescribed high-dose opioids or receiving chronic pain management
  • Prescribed a rotating opioid medication regimen
  • Having a history of substance abuse
  • Receiving an extended-release/long-acting opioid preparation
  • Undergoing a court-ordered opioid detoxification or abstinence program 
  • Newly released from prison and with a history of opioid abuse

Proposal for co-prescribing in primary care

Primary care providers who care for patients with chronic pain must work to reduce opioid-related risks by using routine urine drug testing, assessing state prescription monitoring programs, implementing pill counts, practicing more cautious and constrained prescribing, and referring patients to substance abuse specialists after an assessment indicates deviant drug use behavior.4 The primary care provider must also protect high-risk patients whose pain is being managed with opioids against the potential for overdose. Offering naloxone kits to at-risk patients reduces overdose deaths, and the practice is safe and cost-effective. International and US health organizations consider that providing naloxone kits in primary care to individuals who may witness an opioid overdose, to patients in substance use treatment programs, and to persons being released from prison and jail is a component of responsible opioid prescribing.8