American Society of Regional Anesthesia and Pain Medicine August 2016 - 30

The question, therefore, arises: Should pain physicians be
prescribing naloxone for patients taking opioids for chronic pain?
Dr Coffin believes that the decision to offer naloxone to patients
taking these medications can open up the conversation about "risky
drugs" instead of "risky patients" because it is often difficult to
assess a patient's risk of an overdose accurately when he or she
is starting treatment. According to Dr Coffin, in the San Francisco
program, take-home naloxone medicine has been prescribed to
more than 600 patients taking opioids for chronic pain. Data from
the 2014 survey state that 77% of prescribers had prescribed
naloxone to at least one patient, and 98% said they would likely
prescribe it again. Also according to the survey, 75% of providers
said that prescribing naloxone
helped them communicate
information about opioids with
the patient, and 75% said it
helped open a discussion about
alternatives to opioids for pain
control.5

do not feel they are at risk for overdose, prescribing to all patients
on opioids will help patients understand that naloxone is being
prescribed for risky drugs, not risky patients. Finally, they state that
since about 40% of overdose deaths are related to diversion7, coprescribing naloxone increases the chance the antidote will remain
with the medication. In fact, Dr Coffin sites an incident in which a
police report was filed for stolen narcotic medication in which Evzio
was stolen along with the narcotics.
While the practice of prescribing naloxone for patients in chronic
pain is not yet widespread, preliminary evidence suggests that both
patients and physicians may benefit from its practice. The need for
more studies on the effect of
take-home naloxone on events
such as opioid analgesic
overdoses and on behavior is
crucial.

". . . the decision to offer naloxone to
patients taking these medications can
open up the conversation about "risky
drugs" instead of "risky patients."

To whom should physicians
consider prescribing naloxone?
Some reasons for prescribing may be as follows6:

1. Receiving emergency medical care involving opioid intoxication
or overdose
2. Suspected history of substance abuse or nonmedical opioid use
3. Starting methadone or buprenorphine for addiction
4. Higher dose (>50 mg morphine equivalent per day) opioid
prescription
5. Receiving any opioid prescription for pain plus:
a. Having been rotated from one opioid to another because of
possible incomplete cross-tolerance
b. Smoking, chronic obstructive pulmonary disease,
emphysema, asthma, sleep apnea, respiratory infection, or
other respiratory illness
c. Renal dysfunction, hepatic disease, cardiac illness, or HIV/
AIDS
d. Known or suspected concurrent alcohol use
e. Concurrent benzodiazepine or other sedative prescription
f. Concurrent antidepressant prescription
6. Patients who may have difficulty accessing emergency medical
services due to distance, remoteness, or similar
7. Voluntary request from patient or caregiver
8. Patients returning to high dose when no longer tolerant (eg,
release from prison)
The San Francisco Department of Health believes that perhaps
naloxone should be prescribed to all patients on long-term
narcotics, not just those with the above risk factors. Officials
state that it is often difficult to predict which patients who take
prescription opioids are at risk for overdose. Since many patients

30
2

Although an important use
of naloxone is treatment of
opioid overdose, use of lowdose naltrexone is emerging
as an actual treatment for chronic neuropathic pain states. Lowdose naltrexone (LDN) is thought to inhibit microglial activation.
Microglia, when activated, produce inflammatory and excitatory
states that can cause pain sensitivity, fatigue, sleep disorders,
and general malaise that are common in many neuropathic pain
conditions. Thus, LDN may have an important role in the ability to
treat chronic neuropathic pain states. The medication currently
has to be compounded and is typically used in low doses such
as 1.25-4.5 mg each night. Dr Gary Kaplan, medical director of
the Kaplan Center for Integrative Medicine, has treated hundreds
of patients from ages 9 to 80 years with LDN. He states that it is
best to start at 1.25 mg and increase each week by 1.25 mg to a
maximum of 4.5 mg or the highest tolerated dose. He emphasizes
that the medication should be thought of as one component in
a cocktail of medications that decrease microglial activation.
He often prescribes LDN in combination with celecoxib and/
or other medications such as melatonin and CoQ10. Dr. Kaplan
notes that he often sees an almost immediate improvement in
patients' sleep, which in itself often has a positive impact on pain.
With regard to direct impact on pain control, it may take several
weeks to have an effect. Since it is used at such low doses, there
is usually minimal risk of side effects. While LDN is currently
being used by some pain physicians such as Dr Kaplan, studies
are needed to determine the overall efficacy of this treatment
modality. Of note, the D-isomer of naltrexone has more potent
microglial suppression properties and is currently awaiting FDA
approval for its use.
It is important for pain physicians to be familiar with the use of
naloxone/naltrexone in the treatment of patients suffering from

American Society of Regional Anesthesia and Pain Medicine
2016

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