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Proper Naloxone Use and the Role of the Pharmacist


May 16, 2017

Jeffrey Bratberg, PharmD, a clinical professor in the College of Pharmacy at the University of Rhode Island, co-developed an overdose education and naloxone training program for pharmacists. In 2015, he served as a member of the Rhode Island Governor’s Overdose Prevention and Intervention Task Force, which created and implemented a plan to address the prevention, treatment, overdose reversal, and recovery of individuals affected by opioid use disorders. He’s passionate about increasing access to naloxone, the life-saving agent that reverses the effects of opioid overdose, and his efforts have an added sense of urgency as the current opioid crisis continues to grip the nation.

Dr. Bratberg, whose recent study said opioid-related emergency department visits doubled between 2005 and 2014, took some time to discuss why pharmacists are uniquely positioned to warn patients about the dangers of opioid use and should take the lead in promoting naloxone’s life-saving potential.

What roles do pharmacists play in the proper use of naloxone?

Patients view pharmacies as health care centers, and one of the main roles of pharmacists is to educate the public that naloxone is readily available and that it effectively reverses opioid overdose. They must also ensure that patients who are at risk of overdose — individuals on high-dose opioids or who use opioids and benzodiazepines in combination, for example — have access to naloxone.

Pharmacists should think of themselves as harm reducers during the current opioid crisis. They must counsel patients about the importance of having naloxone on hand to protect themselves and their families, because patients and their loves ones are at risk of overdose if opioids are in the home. Every health care provider also needs to advocate for policy changes that would make naloxone more accessible to patients on opioids.

What’s the best way to emphasize the benefits of naloxone to patients?

Telling patients that they need naloxone because they’re at risk of overdose typically isn’t effective. Instead, it’s more useful to tell patients that they’re at risk of a breathing emergency, even if they take opioids as prescribed and take them regularly at the same time and at the same dose. Pharmacists must remember that they are medication safety specialists and often the ones who explain to patients how opioids work and the harm they can cause. They can also explain that naloxone is 97% effective in reversing opioid overdose. Pharmacists might not be able to get all patients to commit to having the drug on hand, but it’s important that they at least start the conversation.

How does naloxone reverse the effects of an opioid overdose?

It’s a competitive antagonist that prevents opioids from suppressing breathing. Patients often need higher and higher doses of opioids to achieve the same analgesic or euphoric effect, but the same dose can cause respiratory depression. Recent news reports suggest that naloxone-resistant opioids are available on the street. That can’t be true, because mechanistically, naloxone will knock all opioids off receptors that suppress breathing. Some patients might need higher doses of naloxone to achieve that result, but we’re not seeing cases where naloxone fails to revive people who overdose on opioids. There is an important caveat: Naloxone cannot reverse other medications that also cause respiratory depression.

What must providers and patients understand about the use of naloxone?

The biggest misconception is that people use the agent as a safety net to continue abusing drugs. In fact, numerous studies have shown that drug addicts keep using because they don’t want to go into withdrawal. People die of opioid overdose when naloxone is unavailable — it needs to be accessible to high-risk patients in order to save lives. We see people user fewer drugs and more people entering rehab in communities with high naloxone carriage rates, so, again, its availability is key.

What can be done to increase that availability?

Our previous research showed health care providers and patients attach a stigma to the use of naloxone, and that’s the biggest barrier to its widespread use. The way around that issue is to offer the drug to everyone. I’m a big proponent of universal offer, because it’s a cost-effective treatment that isn’t used regularly. And it doesn’t cause harm to patients, even those without opioids onboard.

The bottom line: Naloxone is an easy-to-use, inexpensive drug that can reverse breathing depression caused by opioids. It’s been used during thousands of overdose reversals and has resulted in thousands of lives saved. Healthcare professionals, including pharmacists, and patients should have it on hand at all times. It’s difficult to find a reason why that shouldn’t be the case.

—Dan Cook

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