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In a growing number of states, patients who are taking opioids to relieve severe pain may leave their medical office with a second prescription – naloxone, a life-saving drug that they overdose painkillers powerful.
In California, Virginia, Arizona, Ohio, Washington, Vermont and Rhode Island, new laws and regulations require doctors to "prescribe" or at least offer a prescription for naloxone when they prescribe opioids to patients considered at high risk of overdose. Patients may be considered high risk if they need a high dose of opioids, if they take certain other medications, they suffer from apnea from sleep or they have a history of addiction.
These simultaneous prescription warrants are becoming the latest tactic in a war against an epidemic of prescription and illegal opioids that has claimed the lives of hundreds of thousands of people over the past two decades.
The Food and Drug Administration is considering recommending co-prescription of naloxone at the national level (an FDA subcommittee recently voted in favor), and other federal health officials are already recommending it for some patients . And the companies that make the drug support these changes. It is not hard to understand why: an FDA badysis estimated that more than 48 million additional doses of naloxone would be needed if the agency formally recommended co-prescription at the national level.
Most states have limited the number of opioids that doctors can prescribe at the same time and have significantly expanded access to naloxone. In California, for example, pharmacists can provide naloxone directly to consumers who take illegal or prescription opioids, or who know who is taking it.
In states with co-prescription rules, patients are not required to fulfill their naloxone prescriptions, and those with cancer or living in retirement homes or palliative care are generally exempt.
Kristy Shepard of Haymarket, Va., Was surprised to find a prescription for naloxone that was waiting for her recently when she went to the pharmacy to pick up her opioid meds. His first instinct was not to fill it. She only did it when the nurse at her doctor's office pressured her. The doctor had never told him about Virginia's new law on joint prescription, she said.
"It's so silly, I did not need to use it, unless I get hurt, I'm probably not going to overdose," said 41-year-old Shepard. nurse and hospital administrator who can no longer work and who has applied for disability benefits.
But it may not be as difficult as some people think to overdose prescription pain killers.
"You can take pain medications responsibly, and you may be subject to an accidental overdose, even if everything is done right," said Dr. Nathan Schlicher, an emergency physician in Washington State and a member of the opioid of the badociation of state hospitals. force of intervention.
Two million Americans are addicted to prescription painkillers, according to the FDA. According to the Centers for Disease Control and Prevention, nearly 218,000 people in the United States died from an overdose between 1999 and 2017. Over the same period, opioid prescription deaths increased five-fold CDC data.
In California, doctors wrote nearly 22 million opioid prescriptions in 2017 and 1,169 people died from an opioid overdose. Common prescription opioids include Vicodin, OxyContin, Percocet, Morphine, Codeine, and Fentanyl.
To counter this trend, "states are struggling to find political leverage," said Kitty Purington, senior director of programs at the National Academy for State Health Policy.
Even before the state mandates, pain specialists considered it a good practice to prescribe naloxone with opioid badgesics to some patients, especially those with a history of addiction.
Lobbyist groups of physicians generally oppose the government's practice rules, but some state medical badociations support or at least remain neutral on naloxone concurrent prescription warrants.
The companies that manufacture the drug have spent hundreds of thousands of dollars lobbying collectively to defend their interests at the state level.
Kaléo, which manufactures the Evzio naloxone auto-injector, has spent $ 77,200 in 2017-2018 to pressure California lawmakers to expand access to naloxone, including the law. of the state on concomitant prescription, which requires doctors to prescribe naloxone to patients at high risk. opioids.
In December, Kaleo launched a generic version of the injector at a cost lower than its cost. A Senate investigation revealed that the company had increased the price of its branded version by 600% from 2014 to 2017, bringing it to $ 4,100 for two injectors.
Adapt Pharma, which manufactures the Narcan Naloxone Nasal Spray, spent $ 48,000 lobbying California lawmakers to develop a joint prescription law.
One of the benefits of concomitant prescription rules is that they promote important doctor-patient discussions about the risks badociated with opioids, said Dr. Farshad Ahadian, medical director of the UC San Diego Pain Treatment Center.
"Most providers probably believe that it's better for doctors to self-regulate rather than practice medicine from the legislature's headquarters," Ahadian said. "The truth is that opioids have done a lot of harm to drug users, and we can not help but admit that public safety is essential."
But some doctors – not to mention the patients – have reservations about the new requirements. Some doctors say that it will be nearly impossible for states to enforce warrants. Others worry that naloxone prescribed to patients who live alone is useless because it usually needs to be administered by another person, ideally someone who has been trained to do so.
Patients fear that naloxone prescriptions will unfairly stigmatize them as addicts and force life insurers to deny them coverage.
Shepard, a Virginia-based nurse with four children, worries that her prescription for naloxone may affect her chances of getting additional life insurance – an urgent issue, she said. because his lupus worsens with time.
And a nurse from the Boston area who was working in an addiction treatment program was denied by two life insurers simply because she was carrying naloxone for her patients.
The decision to prescribe naloxone "is a decision that should be made between a doctor and a patient, as every situation is unique," said Katie O. Leary, an executive director of a film production company aged 31. years old living in Los Angeles and diagnosed with complex regional pain syndrome about five years ago.
"So many patients are already jumping through so many hoops to get their medications," said O. Leary. "And if you live alone and you do not have family or friends to take care of you, naloxone might not be really useful."
Opioid addiction and overdoses are a complex problem, and naloxone is only one part of the solution, said Dr. Ben Bobrow, professor of emergency medicine at the faculty of medicine from the University of Arizona.
"In the past, pain was the fifth vital sign, we thought we were doing a bad job if we did not treat it," Bobrow said. "We inadvertently hurt people, we ended up attracting all those people, now it's up to us to help them find others." [ways] to treat their pain. "
California Healthline Digital Journalist Harriet Blair Rowan contributed to this story.
KHN's coverage of these topics is supported by KHN
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