Over the past year, there have been several recurrent themes/articles that we’ve highlighted in the Pediatric Anesthesia Article of the Day. These include the risk of neuro apoptosis following general anesthesia in the very young, COVID, quantitative neuromuscular blockade monitoring, bleeding following bypass surgery, NPO guidelines, perioperative airway management, and the opioid crisis to name a few. Today’s PAAD once again centers on naloxone co-prescription in ADULT patients at risk for opioid overdose. Today’s editorial, original article and its accompanying infographic reveal just how important this issue is and how little we know about this in the pediatric population. Myron Yaster MD
Editorial
Honorio T Benzon, Eric C Sun, Roger Chou. The Opioid Crisis, Centers for Disease Control Opioid Guideline, and Naloxone Coprescription for Patients at Risk for Opioid Overdose. Anesth Analg. 2022 Jul 1;135(1):21-25. PMID: 35709441 1
Original article
Scott D Nelson, Allison B McCoy, Hayley Rector, Andrew J Teare, Tyler W Barrett, Elizabeth A Sigworth, Qingxia Chen, David A Edwards, David E Marcovitz, Adam Wright. Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project. Anesth Analg. 2022 Jul 1;135(1):26-34. PMID: 35343932 2
Opioids now account for 74% of all fatal drug overdoses in the United States with about 1 death every 5 minutes! This opioid overdose death toll has occurred despite steady reductions in opioid prescribing by physicians and is now primarily linked to illicit fentanyl, which Kharash et al described as the “opioid ecosystem” and the “opioid paradox”.3 Is there anything we, as anesthesiologists, can do about it? One promising approach is to make intranasal naloxone more readily available.4-6
Nelson et al2 describe an effort by a multidisciplinary group of experts to increase the rate of intranasal naloxone coprescription by developing an automatic alert notice in their hospital’s electronic health record (EHR) when a high risk of opioid overdose is present. At risk adult patients include “patients receiving more than 90 mg of morphine equivalents/day, young adults (<25 years of age), those with history of opioid or substance use disorder, those who take benzodiazepines with the opioid, and those who are no longer tolerant (after incarceration or after detoxification program)”.1,2 Unfortunately, the rate of naloxone coprescribing by physicians, surgeons, nurse practitioners, and physician assistants has remained low. By using an EHR alert system, Nelson et al. significantly increased naloxone coprescribing. Why intranasal naloxone? First suggested by Dr. Jerome Adams, the U.S. surgeon general in 2018,6 intranasal naloxone can be administered by a bystander, family member, friend, or a first responder easily and safely with minimal training.
OK, why are we posting these adult studies in the PAAD? Although the numbers of patients < 18 years of age in this study was small, Nelson et al.2 found a “dramatic increase in naloxone prescriptions for patients <18 years of age is also impactful in an important and often underrecognized patient age group who are at risk for both unintentional respiratory depression, as well as developing opioid use disorder”. Nelson et al. report a dramatic increase in naloxone coprescription AND a high fill rate. We really don’t know, other than by anecdote, if this actually saved lives.2 The cost is now relatively low, approximately $30-60/dose (and now that I’ve (MY) looked that up in the internet I can’t imagine what my search will do to my inbox!) “Looking at data from our own pharmacies, 62% of naloxone prescriptions had no copay, and 77% were paying $10 or less for naloxone. There were still 5% of prescriptions that were filled and paid at full price. Additionally, many pharmacies have price reduction or patient assistance programs for those in need”.2 Indeed, in California, a prescription for intranasal naloxone may not even require a prescription and can be dispensed by a pharmacist without one.7
On the pediatric side we have a lot of work to do. We know that most opioid prescriptions in children, particularly those who underwent surgery, are neither consumed nor disposed of.8,9 Many of the opioid prescriptions are written for teenagers or for children who have teenagers in the household. Should we be co-prescribing intranasal naloxone to our outpatients?
At the Lucille Packard Children’s Hospital, we (RA) already automatically co-prescribe naloxone for any outpatient receiving both opioids and benzodiazepines (think ortho patients with both muscle and bone injury). For inpatients we follow on the pain service, we also routinely co-prescribe naloxone for anyone that wants it, or if we are sending them home with more than a week’s worth of opioids. At the time of discharge, we also review safe use, storage and have created a smart phase in our EPIC that can be included in their discharge instructions. Unfortunately, this only occurs on inpatients whom we follow and not in outpatients.
Can SPA’s medical informatics committee jump into this and help build EHR prompts, like in this study, to alert prescribers to write naloxone co-prescriptions? And if we make changes, how should we study this? Looking forward to your responses.
PS: From Lynne
An anecdote – my daughter-in-law’s cousin, a non-medical 20-something, went to a community training for nasal naloxone and was given two devices. One week later she saw two people passed out in a car in a Walmart parking lot (with a screaming child in the back seat). She administered naloxone to both and called 911. They both were saved. Maybe in addition to coprescribing to our patients, we should each carry some with us to use in our daily travels through our community. I think Jerome Adams suggested putting naloxone rescue kits in boxes next to the AED boxes in public places.
References
1. Benzon HT, Sun EC, Chou R: The Opioid Crisis, Centers for Disease Control Opioid Guideline, and Naloxone Coprescription for Patients at Risk for Opioid Overdose. Anesth Analg 2022; 135: 21-25
2. Nelson SD, McCoy AB, Rector H, Teare AJ, Barrett TW, Sigworth EA, Chen Q, Edwards DA, Marcovitz DE, Wright A: Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project. Anesth Analg 2022; 135: 26-34
3. Kharasch ED, Clark JD, Adams JM: Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management. Anesthesiology 2022; 136: 10-30
4. Eggleston W, Calleo V, Kim M, Wojcik S: Naloxone Administration by Untrained Community Members. Pharmacotherapy 2020; 40: 84-88
5. Strang J, McDonald R, Campbell G, Degenhardt L, Nielsen S, Ritter A, Dale O: Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs 2019; 79: 1395-1418
6. U.S. Surgeon General Jerome M. Adams Public Health Advisory: Surgeon general's advisory on naloxone and opioid overdose, 2018
7. California department of public health: Your pain is real. So are the risks, 2019
8. Hunsberger JB, Hsu A, Yaster M, Vozzo PT, Gao S, White ED, Yenokyan G, Vickers B, Monitto CL: Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study. Anesth Analg 2020; 131: 866-875
9. Yaster M, Park PS, Hsu A, Roter D, George JA, Shay JE, Monitto CL, Lee BH: Physicians Dispense More Opiod than Needed to Treat Pediatric Pain: A Prospective Cohort Study. Anesthesiology 2015; A1056