Should we worry that take‐home naloxone availability may increase opioid use?

Tas, Basak; Humphreys, Keith; McDonald, Rebecca; Strang, John

doi:10.1111/add.14637

Cited by 13 publications

(10 citation statements)

References 13 publications

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“…We also found that bystanders held misconceptions about naloxone, echoing previous research [ 72 , 73 ], and that these misconceptions inhibited naloxone uptake. Specifically, some bystanders believed naloxone encourages riskier drug use and/or discourages recovery.…”

Section: Discussionsupporting

confidence: 90%

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

et al. 2022

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Background Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose “bystanders” (friends or family of people who use opioids) that may be amenable to intervention. Methods Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020. Results Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one’s drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone. Conclusions Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

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Section: Discussionsupporting

confidence: 90%

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

et al. 2022

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“…Heavey et al [155] found that some participants reported that naloxone access changed the quantity and frequency of use: “chase a bigger high” (page 32; but see also [159]). A recent working paper [156] that suggested a ‘moral hazard’ problem with THN provoked a furor, although most commentators consider the analysis weak and conclude that the evident logic and benefit of THN remain clear [160, 161]. Nevertheless, the intensity of debate from this paper reveals that there is more work to do in ensuring that THN is seen as compatible with health caring roles, as well as managing the perceived risks associated with THN.…”

Section: Barriers To Wider Implementationmentioning

confidence: 92%

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

Strang

McDonald

Campbell

et al. 2019

Drugs

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Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of ‘take-home naloxone’ has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40–50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

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“…This idea is resoundingly rejected by public health authorities as a factor that should limit distribution of, or access to naloxone [ 43 , 44 ]. Not only do public health authorities emphasize the primacy of reduced mortality as the goal of naloxone distribution regardless of increases in substance use [ 45 ], but scant evidence of risk compensation exists. These findings do not weigh in on risk compensation debates, as such an analysis would require a study design allowing for causal inference (this study only tests associations) and such a study should also consider the primary public health goal of net reduction in mortality among patients prescribed naloxone [ 45 , 46 ].…”

Section: Discussionmentioning

confidence: 99%

“…Not only do public health authorities emphasize the primacy of reduced mortality as the goal of naloxone distribution regardless of increases in substance use [ 45 ], but scant evidence of risk compensation exists. These findings do not weigh in on risk compensation debates, as such an analysis would require a study design allowing for causal inference (this study only tests associations) and such a study should also consider the primary public health goal of net reduction in mortality among patients prescribed naloxone [ 45 , 46 ]. The increases in overdose exhibited among patients in the sample data are difficult to interpret without also being able to control for factors like regional increases in illicit fentanyl entering US drug markets.…”

Section: Discussionmentioning

confidence: 99%

Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions

Qeadan

Madden

2021

Addiction

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AimsTo assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose. Design A retrospective cohort study using data from the Health Facts Database. Setting Over 600 United States healthcare facilities. Participants Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work. MeasurementsThe outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).Findings Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose[AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41). Conclusions Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.

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Should we worry that take‐home naloxone availability may increase opioid use?

Cited by 13 publications

References 13 publications

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

Associations between naloxone prescribing and opioid overdose among patients with acute and chronic pain conditions

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