Universal (Intranasal) Naloxone Dispensing
Myron Yaster MD, Lynne G. Maxwell MD, Rita Agarwal MD, Elliot J. Krane MD
At the annual meeting of the ASA in 2019, the surgeon general of the United States, Dr. Jerome Adams, an anesthesiologist, gave a Rovenstine lecture that shook me to my core. He asked the audience: “How many of you have been trained and taken a course in CPR given by the American Heart Association (BLS, ACLS, PALS etc.)?” Everyone raised their hands. He then asked “How many of you have provided CPR outside of the hospital do a patient in cardiac arrest?” A much smaller number of hands were raised. He then asked: “How many of these out of hospital arrest patients survived intact?” Now only a few hands amongst the thousands in the audience were raised. He then asked the question that shook me: “How many of you carry intranasal naloxone to resuscitate out of the hospital opioid overdose victims?” Almost no one raised their hands. He then asked: “Think of how much time and money has been spent on training the entire population on CPR for out of the hospital arrests, when if we simply widely distributed and made available Intranasal naloxone to the entire population, we could save thousands?”
Wow! Regular, long time readers of the PAAD know that I’ve been advocating for more widespread use, distribution, and availability of intranasal Naloxone.(PAAD 01/24/2003 https://ronlitman.substack.com/p/intra-nasal-naloxone especially since it is now available over the counter without a prescription. I think we should ALL be carrying Intranasal Naloxone kits in our daily lives to resuscitate people we encounter outside of the hospital who have overdosed. About a year ago, I made it my routine to keep a kit in my car and when I wear a fanny pack I have a kit in it as well. (Mine is in my backpack, which I take with me everywhere, RA) Indeed, I’ve talked to my kids who are in their 30s-to-early 40s about it and are “non-medical civilians” to think about carrying it as well. I know that one of Lynne Maxwell’s relates, who is also non-medical, resuscitated a couple who had overdosed in a church parking lot saving them and their crying babies in the back seat. In today’s PAAD, we present several articles1,2 calling for UNIVERSAL naloxone dispensing by pediatricians as part of well child care. Co-prescribing naloxone with opioids was also one of recommendations from the recent AAP clinical guidelines on Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings:3 which was highlighted in last weeks PAAD, Opioid Prescribing for Acute Pain part 1- and Opioid Prescribing for Acute Pain part 2. https://ronlitman.substack.com/p/opioid-prescribing-for-acute-pain https://ronlitman.substack.com/p/opioid-prescribing-for-acute-pain-855
We want to make you aware of this position taken by pediatricians and think that anesthesiologists should consider doing this in the context of opioid prescribing for pain, whether postoperative or for non-operative pain. Myron Yaster MD, Lynne Maxwell, and Rita Agarwal
Editorial
McKnight E, Holland-Hall C. Pediatricians' Role in Overdose Prevention: A Call for Universal Naloxone Dispensing. Pediatrics. 2024 Oct 1;154(4):e2024067258. doi: 10.1542/peds.2024-067258. PMID: 39262377.
Original article
Terranella A, Guy G Jr, Mikosz C. Naloxone Dispensing to Youth Ages 10-19: 2017-2022. Pediatrics. 2024 Oct 1;154(4):e2023065137. doi: 10.1542/peds.2023-065137. PMID: 39262344; PMCID: PMC11442117.
“Pediatric deaths from fentanyl have increased more than 30-fold since 2013. Most of these deaths are among adolescents aged 15 to 19 and children 0 to 4 years. Over 40% -60% occur at home, and over 87% are unintentional.”1 “Fentanyl-laced pressed pills are widely available and made to resemble prescription opioids and other prescription medications, such as benzodiazepines and stimulants. Fentanyl has also been found in methamphetamine, cocaine, and marijuana. It is, therefore, not only those with opioid use disorder who are at risk for overdose and death; unintentional ingestion is also common.”1 As we have written about before opioid related deaths overall are decreasing, but they continue to increase in adolescents and young adults (AYA), in addition there is at least one other present in over 66% of these deaths. McNight and Holland-Hall suggest prescribing naloxone to all pediatric patients as part of well child care, just like they discuss firearm prevention, seat belts, etc. By doing this routinely, it “removes stigma and provides an opportunity for open, nonjudgmental discussion around substance use with all patients and families.”1,4 It is possible that there may be unintended consequences, but currently it appears that the potential benefits far outweigh the risks. This article gives a personal perspective: https://csahq.org/2024/09/03/overdose-awareness-day-a-personal-angle-for-advocacy/
“To help youth access naloxone, several methods of distribution, in addition to pharmacies, are available, including dispensing at community events, schools, and naloxone vending machines. Pediatricians and medical professionals can play a role in expanding access to naloxone, including by prescription, by offering it to all youth who report substance use, or who are at risk for opioid overdose.”2
Although we don’t think that it’s very likely that we as anesthesiologists will counsel and offer naloxone to all of our patients, we think we should be co-prescribing it for all, and not just high risk patients who receive outpatient opioids postoperatively. You may wonder, “if naloxone is available over the counter why should I need to write a prescription for it? “ It’s simply a matter of cost. When ordered by prescription for most patients it is free or for a limited co-pay. The over the counter cost is approximately $45 for 2 kits. The stigma of going to a pharmacy and asking for it is still considerable. A prescription at a hospital can avoid this. The other advantage of prescribing it for outpatients going home is simple. PACU nurses can demonstrate how to administer it to the parents and age appropriate patients and review how to recognize the signs and symptoms of overdose.
We wonder if we should make this a quality improvement target? Let’s shoot for 100% co-administration to all patients discharged home from day surgery with an opioid prescription. I (EJK) disagree. Although, I guess there's no harm in dispensing or even administering naloxone when it is unneeded, it seems to me as a universal public health measure, it will cost tens of millions of dollars a year that might better be spent on other public health measures, such as immunizations. I would guess that not one in 10,000 prescriptions for naloxone would ever be used, whereas every immunization, to use that example, would have a positive health benefit.
What do you think? Send your responses to Myron who will post in a Friday reader response
References
1. McKnight E, Holland-Hall C. Pediatricians' Role in Overdose Prevention: A Call for Universal Naloxone Dispensing. Pediatrics 2024;154(4) (In eng). DOI: 10.1542/peds.2024-067258.
2. Terranella A, Guy G, Jr., Mikosz C. Naloxone Dispensing to Youth Ages 10-19: 2017-2022. Pediatrics 2024;154(4) (In eng). DOI: 10.1542/peds.2023-065137.
3. Hadland SE, Agarwal R, Raman SR, et al. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics 2024. DOI: 10.1542/peds.2024-068752.
4. Hadland SE, Schmill DM, Bagley SM. Anticipatory Guidance to Prevent Adolescent Overdoses. Pediatrics 2024;153(5) (In eng). DOI: 10.1542/peds.2023-065217.