A growing number of states are requiring doctors to prescribe a drug overdose antidote alongside prescription opioid painkillers to try to reduce drug deaths.
Under the laws, doctors are to prescribe naloxone when they give patients a certain dose of pills for drugs such as Percocet, Vicodin, OxyContin, and Tramadol or if patients have ever overdosed before. Naloxone can come in the form of a nasal spray, known as Narcan, or an auto-injector known as Evzio.
Arizona, Virginia, and Vermont already have the co-prescribing laws on the books, and lawmakers in California, Florida, New York, Ohio, Texas, and Utah are considering them.
The laws are one of several ways that states are trying to stave off the wave of deaths from opioids, which surpassed 42,000 in 2016 and not only include prescription painkillers but illegal drugs such as heroin and fentanyl. In 2016, 17,860 of the opioid deaths were tied to prescription opioids, including methadone, a drug used to treat addiction, federal data shows.
Most people who become addicted to illegal drugs first abuse prescription medications. But co-prescribing naloxone isn’t only aimed at protecting that group of people. Children can ingest opioid painkillers leftover in their parents’ medicine cabinet, or patients who are facing a serious illness or aging may have forgotten that they already took their pill and accidentally take more than they need.
Naloxone reverses an overdose in all of those cases, saving a person’s life. Opioids slow down the central nervous system, and in higher doses they can make breathing slow or stop, leading to death if someone doesn’t receive naloxone.
But naloxone is not a treatment for addiction. After people are revived, it can cause them to go into painful withdrawal and in some cases become violent. Health officials have pointed to a need to not only to expand access to naloxone, but also to medications that help to treat addiction, such as buprenorphine, as well as to ongoing treatment.
Many addiction treatments are highly regulated and treatment is difficult to access, however. That means that in many instances people are awoken from an overdose several times over the course of their addictions, given that people return to using opioids after being revived.
“Naloxone allows someone another day to have an opportunity to overcome their addiction,” said New York state Sen. George Amedore Jr. “It’s not the whole answer or the cure-all.”
Amedore, a Republican, has introduced a bill in New York that would direct the health commissioner to set up guidelines dictating when naloxone should be prescribed with opioids. He says that the bill should be part of a larger approach to the opioid epidemic that the state legislature has already taken on, including providing access to treatment and ways to involve law enforcement.
The New York lawmaker added that he hopes his legislation helps doctors understand the risks patients face when they prescribe opioids, and that patients also would better understand the risks. As a result, he said, they may tell doctors they do not want to receive a prescription for an opioid at all or be more careful if they do take it.
“It’s one step toward a sensible set of guidelines that will add to more protection and more awareness about the dangers of opiates,” Amedore said.
Adapt Pharma, the drug company that makes Narcan, has been pushing for co-prescribing laws across the country as well as at the federal level.
The company’s chairman and CEO, Seamus Mulligan, said in a recent interview that he sees reducing barriers to accessing naloxone as a “public service obligation.”
“We are trying to do anything we can to build awareness and broaden support,” Mulligan said.
Kaleo, the company that makes the naloxone auto-injector, said in a statement to the Washington Examiner that it “welcomes” co-prescribing legislation.
“We believe that doctors, pharmacists and other healthcare professionals play a critical role in developing and managing a comprehensive treatment plan for their patients, as well as helping a patient and their loved ones recognize the potential risk for opioid emergencies, even when pain medications are taken as directed,” the company said.
State laws on co-prescribing typically direct different agencies to set rules on when naloxone should be prescribed or are tucked into broader legislation.
In Vermont, the rules are tied to recommendations for doctors that include first checking a database to make sure patients haven’t been shopping for painkillers and having discussions with patients about alternatives to opioids. Arizona’s law, which went into effect in late April and includes a broad strategy to tackle the opioid crisis in the state, stipulates that a person who seeks medical help for someone who is overdosing cannot be prosecuted for a drug-related crime. The provision, known as a “Good Samaritan Law,” has passed in at least 10 states.
In Virginia, doctors recommend that high doses of opioids come with naloxone but also that doctors prescribe naloxone when opioids come with a benzodiazepine, such as Xanax or valium. Taken together, opioids and benzos can cause an overdose.
The Virginia requirement has been in place since March 15, 2017, and Adapt Pharma’s sales data show that naloxone prescriptions jumped within a month. Prior to the law being implemented, one naloxone prescription was written for every 1,317 opioids. Afterward, that ratio narrowed to one naloxone prescription for every 44 opioid prescriptions. The latest data, from September, show that prescriptions for naloxone were given for every 133 opioid prescriptions.
Even when a medical professional is required to write the prescription, it is up to the patient to get it filled, notes Diane Powers, spokeswoman for the Virginia Department of Health Professions.
Lawmakers in Congress are still drafting legislation to address the opioid crisis, but federal agencies have addressed the issue before. For instance, guidelines to doctors from the Centers for Disease Control and Prevention recommend they consider naloxone when a patient receives higher doses of opioids or when they have a history of drug abuse.
Industry groups are giving more support. A task force on opioids for the American Medical Association, the nation’s largest doctor group, made a similar recommendation.
Democratic California Assembly member Jim Wood, who is a dentist by training and is chairman of the Health Committee, said the massive tolls incurred from opioid-related deaths necessitated swift action. He has introduced a bill that would required doctors to offer a prescription for naloxone, similar to the Virginia requirement.
“Across the country we lose more than 100 people every day to drug overdoses, primarily by opioids,” he said. “If a plane crashed every day, killing all passengers, we’d drop everything to figure out a way to stop it … Addiction is a disease that destroys the lives of so many people and their families and we need to give everyone one more day and one more chance to seek treatment and rehabilitation.”
