Pharmacists, GPs urged to co‐prescribe naloxone

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Opioid‐related mortality in people taking pharmaceutical opioids for chronic pain is common but can be prevented, say experts

While pharmaceutical opioid prescribing and unintentional overdose deaths continue to rise, health practitioner attitudes towards risk may be contributing to low naloxone prescribing rates, argue experts.

The rate of opioid-related deaths almost doubled between 2007 and 2017, alongside a doubling in numbers of PBS opioid prescriptions.

Most of these deaths involved prescription opioids, write Associate Professor Suzanne Nielsen from the Monash Addiction Research Centre and PhD candidate and GP Dr Pallavi Prathivadi in the Medical Journal of Australia.

“Contrary to what many assume, only one‐third of prescription opioid‐related deaths involved intravenous drug use,” they said.

Among deaths associated with common prescription opioids, including fentanyl, morphine, oxycodone, tramadol and codeine, 49% involved people with chronic pain.

Naloxone is a rapidly acting opioid antagonist currently available in Australia for intramuscular injection or nasal spray.

The intranasal formulation was listed on the PBS in November 2019 as an unrestricted General Schedule medication.

However supply remains low, which A/Prof Nielsen and Dr Prathivadi chalk up to an incorrect perception of to whom naloxone should be supplied.

“Community members, general practitioners and pharmacists frequently perceive naloxone as a medication for people who use illicit opioids, namely heroin,” they point out.

“However, opioid‐related mortality in people taking pharmaceutical opioids for chronic pain is common.”

Recommendations for co‐prescribing naloxone for at‐risk patients with chronic pain include those taking an oral daily morphine equivalent dose of 50 mg or more, taking concurrent benzodiazepines with opioids, having a history of substance use disorder, or having a history of overdose.

While a recent Australian study reported that 78% of patients on Schedule 8 opioids for chronic non‐cancer pain qualified for take‐home naloxone, current national data show that less than 3% of all naloxone supplied is on individual PBS prescriptions.

An additional negligible amount of naloxone is sold over the counter by pharmacists.

“Between 2014 and 2018, an estimated 10,642 units of naloxone were supplied in Australia. Even if a large proportion of this were dispensed to people taking pharmaceutical opioids for chronic pain, it would be vastly insufficient given the 300,000 Australians receiving long term opioids each year,” said A/Prof Nielsen and Dr Prathivadi in the MJA.

GPs prescribe just over half of all opioids in Australia, but attitudes are a huge factor as subjective judgements of overdose risk may pose a barrier to recognising patients who would benefit from take‐home naloxone.

Community pharmacist and proprietor Curtis Ruhnau, whose pharmacy participates in the current take home naloxone pilot, has experienced these attitudes first-hand.

He told AJP uptake of naloxone has been “really slow, really difficult”.

“Every doctor that I talk to has assured me that their patients are OK,” Mr Ruhnau said.

“I think they don’t think want to think that their prescribing could lead to any sort of an adverse outcome.

“We all want to think that our patients read our labels and follow our instructions and would never be at risk of accidentally double dosing themselves, but logic would say that doesn’t make sense,” he said.

“The patients themselves are reluctant without their doctor’s endorsement. It takes a lot of work, a lot of talking from us, to explain to [the patient] why it’s really a good idea.”

While prescribers might not feel that their patients are at risk, the research says otherwise, A/Prof Neilsen points out.

“Four out of five people prescribed long-term opioids for chronic pain meet opioid risk criteria that mean naloxone would be indicated or recommended for them, alongside with a discussion about opioid safety,” she told AJP.

“If prescribers are not aware those risks exist it’s going to be challenging.”

Mr Ruhnau added: “The biggest change in my attitude came from hearing from hearing a real story about overdose.

“Sometimes it’s not the patient themselves, it’s people in that household that are at risk, particularly children.”

Not long ago, he described his experience speaking to a large group at an alcohol and other drugs centre for International Overdose Awareness Day.

“I have two memories I will carry with me from that day. The first is of people crying when they realised there was something that might have saved their friend, family member or loved one,” said Mr Ruhnau.

“The other is hearing a story of being turned away from a community pharmacy when seeking naloxone because, they said, ‘we don’t condone illicit drug use’.”

Dr Jacinta Johnson, a medication safety pharmacist and lecturer in pharmacy at the University of South Australia, agrees with Mr Ruhnau.

“I think hearing from patients and their families has a big influence on attitudes around opioid safety,” she told AJP.

“When you hear stories of serious, accidental harm following prescribed opioid use, where access to naloxone could and would have saved a life they really stick with you. You want to do all you can to make sure the next person in that position has the first aid they need.

“Health professionals tend to shy away from conversations about naloxone with people with pain as they’re worried about offending them, but we have evidence that shows the majority of people prescribed opioids for chronic pain would expect or appreciate a conversation about naloxone with their pharmacist.”

One suggestion to raise uptake from A/Prof Nielsen and Dr Prathivadi is for healthcare practitioners to consider routine co‐prescription of naloxone for patients on strong long-term opioids.

Changing the narrative around take‐home naloxone from “overdose treatment” to “routinely prescribed emergency medication” may help provider attitudes and encourage the normalisation of naloxone prescribing, they submitted.

Naloxone would still cost only a fraction of current PBS‐subsidised opioid prescriptions and overdose‐related hospitalisation costs. It may assist with reducing opioid prescription rates and cost, and “most importantly would save lives,” the authors added.

“The majority of hospital admissions for opioid toxicity involve pharmaceutical opioids. The medications we dispense are causing harm, so it makes sense to supply naloxone as a harm minimisation strategy when supplying that opioid, and coprescribing could help facilitate that,” said Dr Johnson.

In the meantime, pharmacists hope the community pharmacy take home naloxone pilot – which has been extended to 30 June 2021 – will be expanded from New South Wales, South Australia and Western Australia to all states and territories.

The pilot makes naloxone available free to people who may experience, or witness, an opioid overdose.

“We know having to see a GP or pay full price over-the-counter limits access to take-home naloxone,” said Dr Johnson.

“Having a funded program nationally would remove this access barrier and help to save lives.”

A/Prof Neilsen told AJP: “I think the pilot is a really important step, what it’s providing is a really important mechanism so pharmacists can provide naloxone to patients without having cost as a barrier. We need to do a solid effort of upscaling the pilot. That’s just one important step,” 

“A lot of pharmacists can’t identify people getting prescription opioids for chronic pain as people to receive naloxone, and how to raise those conversations. We’ve just developed resources for pharmacists to have those conversations.

“The knowledge base is different, the language we need to use is different – because it’s so different we need to disseminate that information to pharmacists.”

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  1. Angelo Pricolo

    Yes the trial should be extended to all other jurisdictions in Australia of course, but seriously why do we need a trial? If your medical condition changes or you combine opioids with some drugs then even taking the prescribed dose of opioids may trigger an OD. The sensible and equitable way to distribute naloxone is via the PBS and nearly 6000-strong pharmacy network by allowing pharmacists to access the PBS naloxone for their patients without the obstacle of a prescription. Thank you for your article Sheshtyn.

    • Jarrod McMaugh

      Agreed – we have capacity to refer people for a PBS script, or provide it OTC… but for all people using opioids on an ongoing basis, they should have access to naloxone.

      Think of all the elderly patients with durogesic patches, for instance, who get a chest infection later in the year and never recover… was it pneumonia, or was the opioid having a greater impact on their breathing while they were unwell?

      And for those pharmacists who are unsure of whether you should offer naloxone… utilise your RTPM systems (soon to arrive in every state!) – the green/amber/red warning at minimum can help your resolve on whether to offer naloxone, while the actual history in the RTPM system should cement it.

      • Curtis Ruhnau

        Angelo and Jarrod, I think we’re in furious agreement. I assumed that it was called a “trial” or a “pilot” so that it could be rolled out more or less immediately. Waiting for whatever bureaucratic hurdles to be cleared would have just seen more people dying needlessly. At least that was my assumption, and links in to why it had been extended so easily.

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