Continuing Education

The Resurgence of Naloxone

Authors:

Sainath A. Kamath, Pharm D. Auburn University, Harrison School of Pharmacy

Christyn Hicks, Pharm D.

Auburn University, Harrison School of Pharmacy

Rohan Raghuram, Pharm D. Auburn University, Harrison School of Pharmacy

Corresponding Author: Bernie R. Olin, Pharm.D.

Associate Clinical Professor and Director Drug Information and Learning Resource Center Harrison School of Pharmacy, Auburn University

Universal Activity #: 0178-0000-19-102-H01-P/T | 1.25 contact hours (.125 CEUs)

Initial Release Date: November 1, 2019 | Expires: April 1, 2022

Alabama Pharmacy Association | 334.271.4222 | www.aparx.org | apa@aparx.org

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Objectives

● Describe the incidence of opioid-related mortality in both the United States and Alabama

● Describe what naloxone is and how it works

● List the different forms of naloxone that are available

● Describe the laws in Alabama as it pertains to naloxone dispensing

● Discuss the role naloxone plays in opioid overdose prevention

Background Naloxone is an opioid antagonist that is used to counter the effects of an opioid overdose. However, before discussing its pharmacotherapeutic role, it is necessary to take a brief look at why naloxone use has become such an important topic. Millions of Americans suffer from pain each day and are often prescribed opioids for pain relief. The risks of misuse of opioids are great and this misuse has developed into a major public health crisis. Death from drug overdose has now surpassed motor vehicle accident as the leading cause of accidental injury death in the U.S. In 2017, there were 64,795 deaths due to poisoning (including drug overdose), which was an 11.1% increase from 2016.1

According to the National Institute on Drug Abuse (NIDA), more than 130 people in the United States die each day after overdosing on opioids, with 46 being due to prescription opioids.2 In 2017, there were 70,237 overdose deaths, 47,600 of these (67.8%) involved opioids with increases across age groups, racial and ethnic groups, county urbanization levels, and in multiple states.3 The number of overdose deaths in 2017 involving opioids, including prescription opioids (Table 1) and illegal opioids (such as heroin and illicitly manufactured fentanyl - IMF) was six times higher than in 1999.4 The misuse of these opioids, has not only become a public health crisis, but a social and economic burden as well. The Centers for Disease Control and Prevention (CDC) estimates that the economic burden of opioid misuse in the United States is $78.5 billion a year, which includes the

cost of healthcare, lost productivity, addiction

treatment, and criminal justice involvement.5

Table 1: Examples of commonly prescribed opioids

Brand Generic

OxyContin oxycodone

Tylenol #3 codeine/acetaminophen

Norco, Vicodin, Lortab

hydrocodone/acetaminophen

The roots of the opioid crisis can be traced back to the 1990s when there was a push for treating chronic, non-cancer pain with opioids, along with the promise from pharmaceutical companies that opioids were safe.6,7 As a result, healthcare providers began to prescribe opioids in greater numbers. This eventually led to rampant diversion and abuse. The CDC has identified three waves (fig 1), which resulted in the rise in overdose deaths. The first wave began in the 1990s with an increased number of opioid prescriptions. The second wave began in 2010 with rapid increases in overdose deaths involving heroin. As more people were getting addicted to prescription opioids, these drugs began to get expensive and harder to find. This led to the switch to heroin due to it being much less expensive and easier to find on the black market.7 Eventually, heroin supply chains moved from Southeast Asia to Mexico, and this brought about the third wave, which began in 2013. This third wave saw a large number of overdose deaths involving synthetic opioids, particularly IMF.4,8 Mexican cartels had discovered they could mix their heroin with synthetic fentanyl, thereby increasing the high and reducing the manufacturing cost. However, this was done without many people knowing, especially drug users. With heroin and synthetic fentanyl looking alike, and no differentiation when mixed, people who thought they were buying heroin had no idea they were actually buying a much more potent combination of heroin and synthetic fentanyl.8 In the period from 2016-2017, a staggering 46% of states in the U.S. saw statistically significant increases in drug overdose deaths.9 In 2017, more than 191 million opioid prescriptions were

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dispensed in the United States and from 1999 to 2017, nearly 218,000 people in the United States died from overdoses related to prescription opioids. While the overall prescribing rate peaked and leveled off from 2010-2012, and has been declining since, the number of opioids in morphine milligram equivalents (MME) prescribed per person

is approximately three times higher than in 1999.10

The latest data (2016) collected by the National Survey on Drug Use and Health (NSDUH) from 11.5 million people, 12 years old or older, who misused prescription pain relievers, the most common source of the misused drug was from a friend or relative (Table 2).11

Figure 1: CDC

Table 2: Top 3 sources of last pain reliever that was misused (NSDUH data)7

● Given, bought from, taken from a friend or relative (53%) ● Prescriptions or stolen from a health care provider (37.5%) ● Drug dealer or another stranger (6%)

In 2016, Alabama reported 343 opioid-related overdose deaths, a rate of 7.5 deaths per 100,000 which was nearly half the national rate of 13.3 deaths per 100,000. According to CDC data, from 2016 - 2017, Alabama was one of 23 states with a statistically significant increase in drug overdose death rates. Also, in 2017, Alabama was the highest per capita opioid prescribing state in the U.S. with 107 prescriptions per 100 persons.9,12,13

Opioid overdose: risk factors, signs/symptoms, and treatment Opioids are a class of drugs that are derived from the opium poppy plant. These drugs work in the brain, spinal cord, and GI tract by binding to mu, delta, and kappa receptors to relieve pain.14,15

While opioids have an affinity for all three receptors, they have a higher affinity for mu receptors, particularly in the brainstem where the respiratory center lies. When opioids activate these

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mu receptors in the brainstem it can lead to respiratory depression and eventual death.15 Individuals who use opioids may develop tolerance eventually leading to dependence. Tolerance develops when use is so regular that the body becomes acclimated to the drug and needs a higher dose to feel the desired effect.16

An overdose can result from a number of circumstances. Deliberate misuse, prescribing and/or dispensing errors, and poor health literacy are just a few examples that can be attributed to overdose. Due to the high overdose potential that opioids possess, it is important to be able to identify those at risk for overdose, which in turn also identifies those who should be advised to keep an antidote (naloxone) on hand. Those individuals who are dependent on opioids are the most likely to experience an overdose and the risk is increased in those who have recently discontinued use and have lost tolerance to opioids.16 Examples of this include individuals recently detoxified or abstinent from opioids for a short period of time or individuals released from incarceration with a history of opioid use.16 Additional risk factors can be seen in Table 3. While being aware of risk factors that can lead to overdose is vital, it is equally important to be familiar with the signs and symptoms of an opioid overdose (Table 4).16

Table 3: Risk factors for opioid overdose 16

● Individuals who inject opioids ● Individuals taking opioid medications at 50

morphine milligram equivalents (MME) per day or more

● Individuals who use prescription opioids, especially at high doses

● Individuals who use opioids with other drugs such as benzodiazepines or alcohol

● Individuals who have psychiatric illness or medical conditions such as HIV, liver/lung disease or suffer from depression

● Household members of people in possession of opioids

● Individuals receiving rotating opioid medication regimens – at risk for incomplete cross-tolerance

● Opioid prescriptions from multiple providers

Table 4: Signs and symptoms of opioid overdose16

● Constricted pupils (“pin-point”) ● Extreme sleepiness or inability to wake up ● Loss of consciousness ● Slow, shallow breathing ● Skin that is pale, blue or clammy ● Frequent vomiting

● Marked confusion and/or delirium

Treatment Naloxone is a high-affinity opioid antagonist used in the treatment of an opioid overdose. It was patented in 1961 and approved for the use in opioid overdose by the United States Food and Drug Administration (FDA) in 1971.17 It is included in the World Health Organization’s List of Essential Medicines.18

Mechanism and efficacy: Naloxone is an N-allyl derivative of oxymorphone, which possesses an affinity for mu, kappa, and delta receptors, By binding to all three receptors, naloxone reduces the clinical and toxic effects of opioids.19 While all three receptors are responsible for sedation and euphoria, it is only the mu receptor which is responsible for analgesia.18

Naloxone is readily absorbed via intravenous, intranasal, intramuscular, and subcutaneous routes.20,21 It easily crosses the blood- brain barrier due to its high lipophilicity and achieves a high brain-to-serum ratio that is 15-fold when compared to morphine.20,21 The onset of action can range from 2-13 minutes depending on dosage form (Table 5)22 and duration can range from 20 to 90 minutes, which is shorter than most opioids.,23

Because of the short duration, naloxone may need to be re-administered due to most opioids duration of action being longer than naloxone.22 In contrast, orally administered naloxone has poor bioavailability due to extensive first-pass metabolism, making it ineffective for opioid reversal by that route as it would require much higher dosing.20,21

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Table 5: Onset of the different forms of naloxone22

● IV: less than 2 minutes ● Intramuscular and subcutaneous: 2 to 5

minutes

● Intranasal: 8 to 13 minutes

How supplied, administration, and dosing: Naloxone is a bystander-administered medication and a request for it can come from anyone.24 It is supplied for take-home use in the form of intramuscular injection (IM) or as an intranasal spray (IN). The IN formulation is available as a commercial product or a kit that requires assembly. The IM form comes as a syringe/vial combination and also comes as an autoinjector, which can be injected through clothing if necessary. The autoinjector comes with voice and visual instructions to guide the person administering the drug.25 There is no one formulation or product which is more appropriate than the other. Dosage form selection depends on

patient preference and ease of use. While there are differences in delivery forms, all patients should receive the same recommended dosing irrespective of age and medical conditions.24 Further, the FDA’s Anesthetic and Analgesic Product Advisory Committee determined that naloxone dosing should be based on the formulation as opposed to other factors such as patient age, sex, or pregnancy status. Their rationale was that the simplicity of administration outweighed any possible adverse effects from administering too much naloxone.26 It is important to note the differences in dosing and administration as detailed in Table 6. There is not a well-established maximum recommended dose; however, FDA-approved package labels indicate that the initial dose of naloxone is 0.4 mg to 4 mg, based on drug formulation.25 Repeated doses of naloxone may be necessary if the initial dose wears off, but most patients usually respond with the first dose.25 Toxicity data shows that some healthy patients have received 24 mg of naloxone without experiencing toxicity.25,27 Overall, naloxone dosing is based on drug formulation.

Table 6: Naloxone dosage forms comparison 25,27

Drug Product Drug product contents/Directions for use

Evzio® [Naloxone auto-injector]

Contains two active naloxone injections and a trainer. Trainer can be replaced and used 1,000 times and it does not contain a needle and the active ingredient

Follow instructions from device. Inject 0.4 mL into the thigh. Repeat after 2-3 minutes if no or minimal response

Naloxone hydrochloride [for injection]

0.4 mg/mL in 1 mL single dose vials or multi-dose vials Includes one 3mL syringe and a 23-gauge, 1-inch needle per dose dispensed (May be diluted to intravenous infusion using normal saline or 5% dextrose

Do not mix with preparations that containing bisulfite or metabisulfite or any solution that has alkaline pH)

Inject 1 mL in shoulder or thigh. Repeat after 2-3 minutes if no or low response

Narcan® [nasal spray]

4 mg nasal carton contains two blister packs containing 4 mg of naloxone

2 mg nasal carton contains four blister packs each containing 2 mg of naloxone

Administer a single spray in one nostril. Repeat after 2-3 minutes if no or minimal response

Naloxone Intranasal

2 mg/2 mL single dose Luer-Jet prefilled syringe. Includes one Luer-Lok mucosal atomization device per dose dispensed.

Spray 1 mL in each nostril. Repeat after 2-3 minutes if minimal or no response

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Patient selection: Naloxone is only effective in those who have overdosed on an opioid; it does not counter the effects of any other drugs such as benzodiazepines.25 Those patients who should receive or keep naloxone on-hand are the same as those who are at risk for an opioid overdose as listed in Table 3. Additionally, naloxone is safe to use in pregnancy.26,27,28 Precautions and adverse effects Naloxone is generally considered safe and there is no evidence of significant adverse reactions. In the case of opioid overdose, naloxone is a complete reversal agent, counteracting all effects of overdose, but also the therapeutic effects, such as analgesia. While the symptoms of opioid withdrawal will most likely occur after administering naloxone, they are not life- threatening. Finally, hypersensitivity reactions may also occur.27,28

Storage of Naloxone Naloxone should be stored in its original package at room temperature being sure to avoid any exposure to light. If the intranasal and intramuscular dosage forms are exposed to light, the drug chemistry may be altered resulting in decreased effectiveness.16 The ideal temperature for storage is 59 to 77 degrees Fahrenheit. Naloxone’s shelf-life is about 18 months to 2 years if it is stored properly.25 Always monitor the expiration date on the labeling and replace the product accordingly. If an emergency arises, expired naloxone can be administered, although its effectiveness may be decreased. Naloxone should be prepared just before it is ready to be used, such as with the prefilled syringes; once packages are opened and prepared, they expire within 2 weeks.28 It should be stored in a safe and quickly accessible location, away from the reach of children and/or pets. In most law enforcement settings, naloxone can be stored in a safe compartment located inside the vehicle for emergency use purposes. Naloxone can also be stored with automated external defibrillator (AED) units which are easily accessible.29

Naloxone is supplied and formulated for home use as an intramuscular injection and nasal spray.

Counseling For counseling purposes, the San Francisco Department of Health suggests that the word “overdose” may have a stigma attached to it which may elicit a negative response from patients and caregivers. They have suggested using phrases such as “Opioids can sometimes slow or stop your breathing,” or “Naloxone is for opioid medications like an epinephrine pen is for someone with an allergy,” to open the dialog between provider and patient/caregiver.30 It is essential to use words that are not offensive and to create a judgment-free environment. The importance of counseling on the use of naloxone is there for a number of reasons. For one, patients may not be aware of the risks they face while being on an opioid. Also, they may not understand what naloxone is, when to use it, or even how to administer it. It is also vital that patients and caregivers understand how they should respond during an overdose and what to do after naloxone administration (see Table 7).16

Table 7: Overdose response 16

● Check for response to yelling or shaking. ● Check for signs of overdose such as

pinpoint pupils, depressed breathing, or loss of consciousness.

● Call 911. ● Give naloxone. If no reaction in 2-3

minutes, give another naloxone dose. ● Give rescue breaths or chest compressions

if you know how to do them. Follow 911 dispatcher instructions.

● Stay with the person for at least 3 hours or until help arrives.

It is also important to advise the patient and close family members or caregivers to read FDA-approved patient labeling. Patients should recognize the signs and symptoms of opioid overdose (table 4). Instruct patients and family members/caregivers to seek immediate attention

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since the duration of action of most opioids is longer than that of naloxone. Patients and caregivers should be aware that naloxone has limited efficacy for reversal of respiratory depression precipitated by buprenorphine and pentazocine which are partial agonists or mixed agonists/antagonists.27 Thus, higher doses of naloxone may be required. Opioid withdrawal (see Table 8 for symptoms) may be the result of the use of naloxone in patients who are opioid dependent. It is a good idea to inform others, such as family friends, and co-workers, where the naloxone is kept, in cases of emergency so they will be able to easily access it.29 Patients on prescription opioids should ensure that their medication is kept secure at all times, as keeping opioids exposed may provide an invitation for theft. Patients should also know the medication expiration date and know to check it frequently for any discoloration as this may be an indication that a replacement is necessary.22

Table 8: Opioid withdrawal symptoms16

● Sweating ● Achiness ● Shivering ● Gastrointestinal symptoms ● Tachycardia ● Irritability ● Hypertension

Patients and caregivers should be strongly encouraged to speak with their healthcare provider or pharmacist about getting naloxone. When speaking with patients or family who may be hesitant about getting naloxone, stress the fact that it can be life-saving, it is easy to use with low risk of side effects and is not harmful even if given without necessity.16 Finally, advise caregivers that patients may become agitated or vomit after the administration of naloxone. To prevent aspiration, the patient should be placed in the rescue position, after the naloxone is given (figure 2).16

Legislation Naloxone has been utilized by physicians since the early 1970s. At that time, naloxone was only accessible via a prescription from a physician. Under this traditional prescription model, providers could only prescribe naloxone to individual patients under their care who were at high risk of opioid overdose (high risk including being prescribed high doses of opioids, have health conditions that limit breathing, have a history of substance use-related problems, use non-prescription opioids, and/or receive medication-assisted treatment). Then only pharmacists or physicians could distribute naloxone, meaning that anyone who received a naloxone prescription was required to take their naloxone prescription to the pharmacy in order to obtain it.32 However, with the increase in opioid prescriptions and use, states began to pass naloxone access laws. These new laws allowed for naloxone to be accessed by those directly at risk of an overdose, expanding who can distribute naloxone beyond the pharmacist and simplifying the process of obtaining naloxone by eliminating the traditional requirement of going only to a prescriber and/or pharmacy.32

Many states’ access laws now address third-party prescriptions and non-patient-specific prescriptions. Third-party prescriptions are prescriptions issued to a third party, such as a family member, friend, caregiver or emergency personnel who are likely to encounter at-risk individuals. Although, some states require third-

Figure 2: 31

https://www.accessdata.fda.gov/drugsatfda_docs/label

/2015/208411lbl.pdf

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parties to obtain special training or instructions on how to use naloxone; non-patient-specific prescriptions allow for the distribution of naloxone to individuals and organizations that meet certain criteria, thereby eliminating the requirement of seeing a prescriber beforehand. This makes naloxone more accessible to individuals who are at-risk for an opioid overdose but not able or unwilling to see a physician or prescriber due to reasons such as insurance status, stigma, and lack of transportation.32

Non-patient-specific prescriptions warranted the need for more naloxone access laws and regulations. One of these is the expansion of the pharmaceutical distribution of naloxone. This expansion is attainable via standing orders, which are written by prescribers authorizing pharmacies to dispense naloxone to patients without a prescription from a provider. Additionally, the expansion is attainable by protocol orders which are similar to a standing order; however, protocol orders come from a state board of health or pharmacy licensing board instead of a licensed prescriber. These orders come from the state level and pharmacists in the state who follow the order are eligible to dispense naloxone without a patient-specific prescription. Collaborative practice agreements also help this expansion. This is an additional form of agreement between prescribers and pharmacies or pharmacy chains within a state. Much like protocol orders, collaborative practice agreements allow the dispensing of naloxone without an initial requirement of a patient seeing a prescriber. Pharmacists have also been given prescribing authority, which allows them to prescribe naloxone without an order from a prescriber such as a physician or agreement from a pharmaceutical board or board of health. Pharmacists are required to complete approved training, record each time they distribute naloxone, and provide training or informational materials to patients receiving naloxone.32

Also, permitting the distribution of naloxone in community settings is another regulation that allows naloxone access. This is useful in community-based programs whose priority is to educate the community and respond to overdoses, including responding to overdoses via providing naloxone at little or no cost. This allows naloxone

to be distributed via a standing order without the need of a licensed prescriber on the premises when there is life-threatening emergency.32 Dispensing Naloxone in Alabama In Alabama, physicians, dentists, and pharmacists are allowed by law to dispense naloxone. HB208, the Good Samaritan Law, was signed into law in 2015 which allowed any physician or dentist acting in good faith and exercising reasonable care, to directly or by standing order prescribe naloxone.32 This includes scenarios such as:

● A patient seeking naloxone is at risk of experiencing an opiate-related overdose

● The individual seeking naloxone is a family member, friend, or otherwise in the position to assist the individual at risk of experiencing an opiate-related overdose

● Individuals who have a good faith belief that another individual is experiencing an opiate-related overdose and they exercise reasonable care in administering naloxone. The individual administering the naloxone should include the receipt of basic instruction and information on how to administer the naloxone.32

Any licensed pharmacist may dispense naloxone to any of the following:

● An individual at risk of experiencing an opiate-related overdose.

● A family member, friend, member of a fire department, rescue squad, volunteer fire department personnel, or other individuals, including law enforcement, in a position to assist an individual at risk of experiencing an opiate-related overdose 32

In 2016, HB379 was signed into law providing the state health officer or a county health officer the authority to write a standing order for dispensing naloxone.32 Cost and billing Evzio® 2 mg/0.4 mL is $4,100. Pharmacies and/or patients should call their insurance directly regarding prescription coverage. Most times, prior authorizations are required for copay coverage. Some patients with private insurance may be eligible to have Evzio® delivered via mail order

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directly to their homes without a copay. Evzio® also has patient assistance programs that provide assistance for prescription coverage to patients without insurance.28 NARCAN® nasal spray 4 mg cost $125 and this includes two nasal sprays. Public programs and personnel, such as first responders and community naloxone programs, are able to purchase NARCAN® from ADAPT Pharma® which is a privately-held company committed to expanding access to naloxone to help aid in opioid overdose and addiction.,34 This company also provides free cartons of NARCAN® to high schools, colleges and universities.34

Naloxone “kits” are also available in the United States. Patients should check with their local health department, as some may offer naloxone at no charge. Also, some insurance plans, including Medicaid and Medicare in some states may also cover the kits.25

● Naloxone kit (for nasal administration): ~$80 ● Naloxone kit (for IM administration): ~$30

Legal and Liability Concerns Naloxone is FDA approved for managing opioid overdose, so there is no liability as long as the prescriber adheres to the general rules of professional conduct. Given this, health care professionals should not be concerned about legal risks and the prescribing of naloxone in managing opioid overdose.16

Additionally, it should be noted that as of July 2018, 46 states and the District of Columbia have instituted Good Samaritan laws which have been enacted to encourage bystanders to assist those who are overdosing without fear of being arrested for drug-related crimes.35 Recovering from an overdose and prevention An overdose can affect many people, from the patient to family and friends. Survivors have many emotional consequences to deal with, along with the physical effects of overdose. Family and friends often have a unique set of emotions to deal with as well, ranging from guilt to inadequacy. The first step in recovery should be finding a network of support. If the survivor’s problem is pain, a referral to a pain specialist should be considered. If addiction is the issue, then the survivor should

consider seeking addiction treatment and counseling.16

Prevention is key in preventing overdose deaths. The Substance Abuse and Mental Health Services Administration (SAMHSA) has outlined five strategies to prevent overdose deaths.16

1. Encourage providers, persons at high risk, family members, and others to learn how to prevent and manage opioid overdose.

2. Ensure access to treatment for individuals who are misusing opioids or who have a substance use disorder.

3. Ensure ready access to naloxone. 4. Encourage the public to call 911. 5. Encourage prescribers to use state

prescription drug monitoring programs.

Finally, when counseling patients and family, SAMHSA makes the following recommendations on avoiding opioid overdose:16

1. Take medication only if it has been prescribed to you by your doctor and make sure you discuss all the medications you are taking with your doctor.

2. Do not take the medication more than instructed.

3. Call your doctor if your pain gets worse. 4. Never mix pain medications with alcohol,

sleeping pills, or any illicit substance. 5. Learn the signs of an overdose and how to

use naloxone to keep an overdose from becoming fatal.

6. Teach family members and friends how to respond to an overdose.

7. Dispose of unused medications properly, such as through drug take-back programs.

Pharmacist’s Role There are a number of things pharmacists can do in assisting with the prevention of opioid overdose and promoting naloxone. Pharmacists can assess an overdose risk by reviewing all of a patient’s medications (e.g., is patient also on any benzodiazepines?), providing patient education, and promoting medication safety. Keeping track of the source of prescriptions such as are they coming from one or multiple prescribers? Communicating

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with prescribing physicians is key as well. The pharmacist should provide naloxone and naloxone counseling to any patient who meets any of the criteria for overdose risk. When speaking with patients, it is key to use non-judgmental and non-threatening words to ensure that the patient/caregiver does not feel any stigma when it comes to discussion of overdose prevention and treatment. Finally, the pharmacist can provide effective and thorough counseling on how to use naloxone appropriately, and what to expect during an overdose, providing caregivers/family the tools necessary to help ensure a positive outcome in the event of an overdose. Conclusion The current opioid crisis began in the 1990s with the false belief being promoted that these medications were safe and that the risk of addiction was low. For physicians and patients alike, this was the light at the end of the tunnel. Finally, a “safe” option for those millions of people who suffered from chronic pain. Prescriptions were being written in record numbers and by the late 1990s, the opioid crisis started to take root. It was not long before signs of opioid misuse and diversion began showing in communities across the country. In 2010, the epidemic moved into its second stage, where heroin became the new high due to it being cheaper and easier to find when compared to prescription opioids. This led to record numbers of not just heroin users, but in overdose deaths as well. The opioid epidemic had established its firm grip in 2013 when an increasing number of deaths were being attributed to synthetic opioids, particularly illicitly manufactured fentanyl. Mexican heroin cartels found that they could increase their profits by using less heroin and cut it with synthetic fentanyl. It was cheaper to make, more profitable, and produced a much

higher high compared to heroin alone. No fourth wave has been identified, yet the deadly epidemic continues.8 Alarmingly, from 2016-2017, 46% of states in the U.S. saw statistically significant increases in drug overdose deaths.9 With no end to the epidemic in sight, measures need to be taken to curb the number of deaths from opioid misuse. Enter naloxone. Naloxone has been approved for use by the FDA since 1971, but only recently has it become a focal point in the opioid crisis and the driving force in the prevention of deaths from opioid misuse, by reversing respiratory depression, which is the primary cause of death from an overdose. Given naloxone’s key role in this current crisis, creating and expanding awareness and availability of this drug is crucial. Getting naloxone into the hands of millions who need it is the first big step. Many states have passed laws that allow patients and family members to easily get naloxone by instituting standing orders which allow for the dispensing of naloxone without a prescription. States have even passed Good Samaritan laws to encourage bystanders to assist a person who is overdosing without any legal repercussions. The second step which must be taken is removing the stigma that patients and family members face with opioids when discussing opioid overdose. This is where health care providers, from physicians to pharmacists, can work together to properly educate and counsel patients on naloxone, using non-judgmental speech, so patients and family members can move forward in tackling the problem. The war with opioids wages on. However, by continuing to ensure easy access to naloxone, educating the public, and spreading awareness on the vital role it plays, perhaps the collateral damage, in the form of overdose deaths, can be greatly reduced.

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