Jan. 17 2017

Should Emergency Physicians Prescribe Naloxone?

There is an epidemic of opioid overdoses in the US, and emergency physicians have a significant role to play in reducing the death-toll from opioids. According to the Centers for Disease Control and Prevention, 78 people died from an opioid (e.g. heroin or prescription narcotics) overdose each day in 2014. The costs to the health care system are enormous, measuring in the tens of billions of dollars per year. Unlike many drugs of abuse, there is a well-studied and safe antidote, naloxone (or Narcan©), that can immediately reverse the effects of the opioids, like the slowed breathing and unconsciousness, within seconds. Naloxone can, quite literally, bring people back to life.

As an emergency physician, I have cared for dozens of individuals who presented to the emergency department (ED) after an overdose. I have also witnessed the miraculous effect that this one, relatively cheap, medication can have on saving lives. However, those people who made it to the hospital were the “lucky ones” who had the fortune of a friend or good Samaritan calling 911. I remain troubled by the large numbers of people who overdose and die before medical care arrives. 

Ask yourself, what if every emergency physician was required to prescribe naloxone to patients who they felt were at risk of an overdose? How many lives could be saved with broader availability of naloxone in the community?

Up until recently, the only people with access to this life-saving medication were medical and pre-hospital care providers. A few years ago, the FDA approved naloxone auto-injectors (similar to an EpiPen©) that individuals can take home and self-administer (or to a friend) in the setting of a potentially fatal overdose. Despite this, many states continue to have backwards and misguided policies that do not allow physicians to prescribe naloxone; its use is restricted to medical personnel only.

Many policy-makers believe take-home naloxone will lead to more overdoses and higher risk-taking behaviors. There is a widespread myth that individuals will use larger quantities of heroin, for example, because they have a heightened sense of security from having a naloxone auto-injector at hand. This has been largely debunked by research studies, but this belief still persists. Just as needle exchange programs were shown to be an effective harm reduction strategy and did not encourage more IV drug use, similarly, naloxone auto-injectors are a way to prevent death and morbidity.

Others believe that making naloxone universally available will lead to fewer individuals calling 911 and receiving a medical evaluation. This is concerning because the half-life of naloxone is quite short, and its effects could wear off too quickly, resulting in unexpected death. Second, most EDs provide ancillary services to patients with drug addiction, for example evaluation by a chemical dependency counselor or referral by a social worker to rehab. The opportunities for behavioral intervention would be lost if those revived by naloxone simply stayed at home. Ultimately, however, I would argue that the benefit to having and using naloxone outweighs these potential risks.

With the availability of this life-saving medication, it is paternalistic of federal and state governments to restrict its uses to trained medical providers only. The FDA has already assured the safety and efficacy of this treatment. The government should not be able to place further restrictions on its access and use. 

According the the Siracusa Principles of 1984, right to life is a non-derogable human right and nothing should violate this. And, if that right to life comes at the cost of a medication, then that is justified. The device is no different than an Epipen©, which are prescribed on a daily basis to individuals and parents to prevent anaphylactic shock. The difference is that the recipients are an already marginalized, vulnerable group of people with drug addiction and often mental health disease rather than a child at school who inadvertently eats a peanut.

I believe emergency departments have a unique window into this epidemic as the majority of patients who overdose will be resuscitated and undergo an evaluation in an ED. With this specialized insight comes enormous responsibility. Emergency physicians have an opportunity to treat the immediate condition of an overdose, as well as prevent the consequences of future ones.

We, as a nation, need to address this opioid epidemic head-on. We need a multi-factorial approach which includes increasing drug addiction and rehab services, strengthening drug addiction education in schools, and enforcing responsible opioid prescribing habits among physicians. Arguably the most important factor in this response will be federal and state policies that support greater transparency on this issue and empower marginalized groups to seek help. One critical first step is making naloxone widely available in the community.

—C. Hayes Wong