Medical providers take an oath to protect the health of their patients, but in some instances, doctors may fail to prescribe life-saving medications over legal concerns, logistical barriers, or even personal prejudices. Such is often the case with naloxone, a medication used to reverse drug overdose from opioid pain relievers such as OxyContin, Percocet, or heroin. Naloxone has no potential for abuse, few side effects other than opiate withdrawal, and is available nationwide via prescription. With drug overdose now claiming 38,000 lives a year - more than car accidents - one would expect the antidote to be more widely accessible, so why is the largest barrier to access often the very people who could, or should, be naloxone's greatest champions?
1. Most Physicians Have Never Heard of Co-Prescribing Naloxone to Opiate-Dependent Patients
While naloxone has been around for decades as an antidote to opioid overdose, until recently only hospitals, paramedics and emergency departments had access. Most general practitioners and even physicians who work with chronic pain patients have never used naloxone and may not have even heard of it.
Dr. Paul Martin is the Chairman of the Asheville Buncombe Drug Commission, a group that meets to strategize on how to reduce adverse effects from drug and alcohol dependency. He conducts trainings in western North Carolina for Project Lazarus, a nonprofit that works in overdose prevention, and educates physicians on best practices for opioid prescribing, including naloxone co-prescription, or prescribing naloxone to patients who also take opioid pain relievers. Co-prescription is fairly common in instances where an antidote is available; for example, physicians often co-prescribe glucagon to patients with blood sugar problems. The EpiPen is also available to people who have severe allergic reactions.
"For most participants in the trainings, naloxone is not even on their radar," explains Dr. Martin. "I wouldn't have thought of prescribing naloxone to a patient either until I become involved [in overdose prevention work]. Now that know more about the medication, its effects, and relatively low risk, I would certainly consider prescribing it."
Dr. Martin believes that education is key to encouraging physicians to prescribe naloxone. Once medical providers become aware of naloxone, its life-saving properties, and low risks associated with administration, they are typically more open to consider it for some of their patients. To this end, the FDA is encouraging physicians to prescribe naloxone not only to opiate using patients, but also to the family and friends of those patients who may be present during an overdose. Nationally, lay people have reversed over 10,000 overdoses with naloxone.
2. Physicians Might Not Know Where to Get Naloxone
Because naloxone is a prescription medication, most insurance companies cover its cost and patients can obtain it from their local pharmacy (though the pharmacy may have to order it). Even without insurance, naloxone typically costs less than $20 a dose, a small investment in a medication that could potentially save a life. Additionally, in some areas, community organizations provide free overdose prevention kits, which include naloxone and other items such as informational pamphlets on how to administer it, syringes or a nasal adapter to spray naloxone into the nostrils, and perhaps an educational DVD or face mask for rescue breathing.
3. Many Physicians Are Afraid of Being Sued
Legal concerns are a major barrier that prevents physicians from prescribing naloxone, particularly concerns about naloxone being administered by someone with no medical training, or to someone other than the patient to whom it was prescribed. The good news? These fears are largely unfounded, as no provider has ever been sued for prescribing naloxone. Even so, fourteen states have taken extra precautions by passing new laws that remove civil and criminal liability from any provider who prescribes naloxone to a patient or loved one. Additionally, many state medical boards have released statements to encourage their licensees to co-prescribe naloxone. As many of these new laws and medical board statements are relatively new, physicians may not be aware of them, so it's important that government and community programs reach out to medical providers with this information.
4. Some Physicians Are Concerned that Prescribing Naloxone Encourages or Enables Drug Use
Some physicians express concerns about whether or not co-prescription of naloxone "sends the wrong message" about problematic drug use. Though few providers would refuse to treat a diabetic because he hadn't adhered well to dietary restrictions or deny antibiotics to someone with STIs because she'd had unprotected sex, many routinely turn drug users away because they see their ailments as self-inflicted and deserved. That a doctor would refuse to treat a patient due to personal prejudices reveals just how deep stigma against drug use runs.
Dr. Logan Graddy is a private practice physician who also serves as the Medical Director for the North Carolina Harm Reduction Coalition, a nonprofit agency that distributes overdose prevention kits, including naloxone, to at-risk individuals and their families.
"I can understand concerns about [prescribing naloxone] because I've had my own struggles with it at times," he says. "But I think when you understand the overdose epidemic you realize how important it is for the medical community to respond to this crisis. We should not be writing people off because they are using drugs, or thinking that in order to stop using drugs people need to learn a lesson by almost dying...Naloxone distribution programs are an evidence-based harm reduction strategy that saves lives."
Ultimately the country has a long way to go when it comes to increasing access to naloxone. Whether the barriers are legal, logistical, or personal, naloxone is still not in the hands of enough people who need it to prevent accidental death from overdose. The good news is that we are making strides. In 2007, the majority of physician respondents to a national survey said they would never consider prescribing naloxone, yet in 2013, a similar survey showed providers more open to the idea. Community programs that distribute naloxone continue to grow and more states are passing laws to protect physicians and bystanders who prescribing or administer the antidote. Education continues to be an important part of raising awareness among physicians about naloxone, how to access it, legal protections that may exist in their state, and combating stigma. Ultimately, the battle to save lives from overdose will be a tough one, but getting medical providers on board may be exactly what is needed to turn the tide.