Naloxone and opioid co-prescribing is not necessary for all patients whose chronic pain is being managed in primary care; it is recommended only for patients at high risk for opioid overdose. Patients with any of the following factors are considered to be at high risk4:

  • History or diagnosis of substance abuse, including alcohol abuse
  • Need for high doses of opioids
  • Being introduced to and/or continuing methadone; methadone has a long-half life, so the risk for toxic accrual is increased during therapy initiation
  • Polypharmacy, especially co-administration of benzodiazepines
  • Comorbid psychiatric disorders, especially an increased risk for suicide
  • Impairments of cognitive function that could result in the ingestion of excessive amounts of opioids

The Centers for Disease Control and Prevention also recommends that a history of overdose be considered a risk factor and defines a high opioid dose as one equal to or greater than 50 MME (morphine milligram equivalents) per day.2 The World Health Organization released guidelines for the community management of opioid overdose in 2014, adding to its list of high-risk opioid users those with other significant medical conditions (HIV infection, liver or lung disease) and members of the households of people taking high-dose opioids.13

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Education is an essential component of the training of primary care providers who are co-prescribing naloxone while treating high-risk patients with chronic pain. Training must be provided not only to the patient with chronic pain who is receiving the opioid and naloxone co-prescription but also to the laypersons who may be close to them (ie, family members, household members, friends). The training provided to potential overdose witnesses differs from the training given to the individuals who disclose opioid use. First, these persons do not use opioids themselves and may not be acquainted with substance use and signs of overdose. Thus, an opportunity to offer education regarding substance use and addiction to reduce stigma is recommended. Also, such training may encourage the third party to talk with the individual at risk for overdose about substance use and overdose. Therefore, training can be beneficial in teaching the third party to provide support beyond the administration of naloxone.21

Naloxone education should include how to identify an overdose, call emergency services, and administer naloxone.4 Evidence has shown that education can be provided briefly as well as at length.4,12 It can be provided by a clinician directly, sent to the patient’s home in written form, or recorded and delivered by a rescue device.4

Screening tools to identify at-risk patients, standardized prescribing guidelines to help providers prescribe naloxone appropriately, and patient education resources are available at PrescribeToPrevent.


Overdose is a risk in the management of chronic pain with opioids in primary care. Because clinicians are on the front lines in the care of patients with chronic pain in rural and remote areas, it is essential that these clinicians institute the practice of providing prescriptions for naloxone along with opioids in their protocols for the treatment of patients at high risk for opioid poisoning. Further research on the use of naloxone co-prescribing in primary care is encouraged in the realm of nursing because few data are currently available in primary care medicine or nursing. Furthermore, it is essential that clinicians in primary care lobby for broader naloxone access. 

Lesley Cooper, DNP, FNP-C, is a nurse practitioner currently working in Bahrain.


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