American Society of Regional Anesthesia and Pain Medicine August 2016 - 29

Naloxone, Opioid Overdose, and Chronic Pain

ccording to the Centers for Disease Control (CDC), health care
providers wrote 259 million prescriptions for opioid or narcotic
painkillers in 2012. Although these medications have a true
therapeutic value for some individuals who suffer from intense pain,
the incidence of misuse, abuse, and overdose from opioid medications
has been steadily rising over the years. In fact, drug overdoses from
these medications have overtaken motor vehicle crashes as the
number one cause of injury death in the United States.1
Misuse can sometimes be entirely unintentional, especially for
older individuals. Serious memory issues, dementia, or Alzheimer's
disease can exacerbate this risk, and it is important for caregivers
to carefully monitor their loved ones' medications.
Polypharmacy, or the use of multiple medications to maintain
coexisting health problems, also makes it difficult to responsibly
manage prescriptions such as opioid painkillers. A CDC study
revealed that 76% of Americans aged 60 years and older use two
or more prescription drugs and 37% use five or more.2 In addition,
many prescription and nonprescription medications, supplements,
and vitamins can have significant side effects and interactions with
one another. Adding alcohol to this mix increases the risk of an
adverse reaction or overdose even further.
It is vital for both the patient and physicians to engage in a serious
discussion about these medications when they are prescribed.
This includes conversing about the proper way to take these
medicines, acknowledging drug and alcohol interactions, and
learning how to recognize and respond to an accidental overdose.
"This can be an uncomfortable conversation to have," says Dr
Anita Gupta, vice-chair and associate professor at Drexel University
College of Medicine and co-chair for the American Society of
Anesthesiologists' ad hoc Committee on Prescription Opioid Abuse.
Part of this discussion should include education about signs of
potential overdose. According to the World Health Organization,
a combination of three specific signs can indicate an opioid
emergency. This is known as the "opioid overdose triad" and
includes slowed or even stopped breathing (respiratory depression),
loss of consciousness, and very small pupils.3

physicians to prescribe
naloxone for patients taking
opioids for chronic pain
to reduce overdoses and
mortality; however, this
strategy has a compelling
rationale.
A preliminary 2014 survey
indicated the practice of
prescribing naloxone to
patients prescribed opioids
Lynn Kohan, MD
is carried out in at least
Assistant Professor
16 states. Dr Philip Coffin,
Department of Anesthesiology
director of Substance
University of Virginia
Abuse Research of the HIV
Prevention Section at the
Section Editor: Magdalena Anitescu, MD, PhD
San Francisco Department
of Public Health, states that,
in San Francisco, providing a prescription for take-home naloxone
is now recommended for all patients taking opioids for chronic pain
at public health primary care clinics. He states the program was
well received by primary care providers according to the survey.
In addition, other sites that are providing naloxone to patients
receiving chronic opioids for pain include the US Department of
Veteran Affairs; the US Army base in Fort Bragg, North Carolina; and
Denver Health Medical Center.5

Figure 1: Evzio is an autoinjectable form of naloxone.
Evzio® 0.4 mg
#1 two pack
Prn for opioid overdose
Each prescription comes with two single-use autoinjectors and one blackand-white trainer. Most adults learn how to use it within 60 seconds.

Of growing interest is whether naloxone (an opioid antagonist)
should also be part of this discussion. Naloxone is available in
multiple forms: intramuscular (IM) may be less attractive because
it involves needles; intranasal (IN), which is sometimes difficult to
obtain at a pharmacy; and a new Food and Drug Administration
(FDA)-approved autoinjectable form called Evzio (Kaleo Inc,
Richmond, VA; Figure 1). Most private health insurers, Medicare,
and Medicaid pay for naloxone.
The CDC states that naloxone has reversed more than 10,000
opioid overdoses since 2014.4 It is not yet common practice for

American Society of Regional Anesthesia and Pain Medicine
2016

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Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2016