WITH the rate of fatal opioid overdoses almost doubling in Australia between 2002 and 2018, experts are calling for the routine co-prescription of emergency reversal agent naloxone to opioid users.

According to the authors of a Perspective in today’s MJA, the people most at risk may not be aware how they can prevent harm, meaning more non-judgmental conversations with these patients are needed.

In Australia, opioid mortality has almost doubled from 3.8 deaths per 100 000 Australians in 2007 to 6.7 per 100 000 in 2017. Fatal opioid overdoses have increased from 482 per 100 000 in 2002 to 900 in 2018.

Most of those deaths involved prescription opioids and, contrary to what many people believe, only a third of those involved intravenous drug use.

Associate Professor Suzanne Nielsen, Deputy Director of the Monash Addiction Research Centre, and co-author of the MJA article, told InSight+ there were many misconceptions about opioid overdoses.

“People assume those deaths must be people who are using prescription opioids non-medically or are doing something wrong,” she said.

“But actually, when we look at mortality data, we see that an important portion of these deaths are people who are prescribed prescription opioids for pain and aren’t using illicit substances. There are real risks of opioids in these populations.”

Dr Hester Wilson, GP and Chair of the Royal Australasian College of GPs’ Special Interest Group into Addiction, agreed that many of those overdosing are people who wouldn’t consider themselves at risk from drugs.

“You’re working with people who may not recognise their own risk; family members who don’t recognise the risk,” Dr Wilson said.

By prescribing a medication such as naloxone, doctors and pharmacists have an opportunity to talk about the risks of opioids with their patients.

The MJA article noted naloxone’s use as a reversal agent for intravenous drugs may stigmatise opioid users further. It’s something that concerns CEO of Pain Australia, Carol Bennett.

“We don’t want to make the situation worse. We want to address stigma,” she warned.

Ms Bennett highlighted that when doctors and pharmacists talk about naloxone, they needed to be clear about the rationale for the medication, and the patient needed to understand its benefits.

“Unless that explanation is worked through with a patient and a doctor, to me, it feels like something that might be imposed on people,” Ms Bennett explained.

Associate Professor Nielsen agreed.

“It’s important for us to think about how to have those conversations so we’re not making people feel afraid of their medicines, but we’re empowering them to know what their risks are and to do something about it.”

In the MJA article, Associate Professor Nielsen and her co-author, Dr Pallavi Prathivadi, a GP and PhD candidate at Monash University, suggested there could be language changes to explain the benefits of naloxone without stigmatising the patient.

“Changing the narrative around take-home naloxone from ‘overdose treatment’ to ‘routinely prescribed emergency medication’ may help provider attitudes and encourage the normalisation of naloxone prescribing,” they wrote.

For Dr Wilson, it’s simple.

“For me, naloxone is like the Epipen of opioid use,” she said.

Prathivadi and Nielsen wrote that “take-home naloxone for people on opioids is analogous to intramuscular glucagon for patients with diabetes on insulin, or auto-injectable adrenaline for anaphylaxis”.

“Most people are unlikely to need these emergency medications, but in the case of profoundly dangerous adverse events, naloxone, like glucagon or adrenaline, has a life-saving role.”

By talking about managing risks, it also opens the conversation about the signs of opioid toxicity. Associate Professor Nielsen said many people still didn’t know what they were.

“We still hear in coroners’ cases that even though a person has shown signs of opioid toxicity, (the classic sounds such as snoring and gurgling in their sleep) the person never woke up. Even though people were aware of those symptoms, they didn’t know they were signs of opioid toxicity,” she told InSight+.

All experts agreed that education needed to extend beyond the patient. Family members and carers need to understand not only the risks of opioids but also how to use naloxone. One way is through easy-to-read consumer resources that GPs could discuss with their patients then send home for other family members to read.

“These resources we send home with patients explain why we’ve offered naloxone so they can explain it to family members, so someone in the home knows naloxone is there and when and how to use it,” Associate Professor Nielsen said.

“It’s not much value having naloxone in the home if no one knows how to use it.”

According to Dr Wilson, pharmacists could also take a role in risk minimisation. When someone came in with an opioid script, they could highlight the fact that naloxone was available over the counter.

“When family members are going to pick up these medications, ask them whether they’ve thought about naloxone, tell them to chat to their doctor about it,” she said.

Until we reduce opioid stigma and empower patients to understand their medications, we won’t see any reduction in opioid mortality.

“All of us need to look at the role that we play as health professionals to minimise that risk,” Dr Wilson said.


Naloxone should be co-prescribed with opioids for long-term use
  • Strongly agree (49%, 46 Votes)
  • Agree (27%, 25 Votes)
  • Neutral (13%, 12 Votes)
  • Disagree (10%, 9 Votes)
  • Strongly disagree (1%, 1 Votes)

Total Voters: 93

Loading ... Loading ...

6 thoughts on “Co-prescribing naloxone: taking the stigma out

  1. Suzanne Nielsen says:

    In reply to Mary Britton. Great (and common) question – this has been explored in research, and there is no evidence that supplying naloxone leads to people increasing their opioid use. In addition, a well cited study in the Annals of Internal Medicine also showed the following naloxone supply to people prescribed opioids, there is a reduced likelihood that that individual would have a later opioid-related ED attendance, with no change in opioid dose. This is a common query so it is great there is evidence to show this shouldn’t be a concern.

  2. edwin vivares says:

    How about adding naloxone to all oral opioid analgesics ?

  3. Dr Tony Sara says:

    this approach has been proven in the literature to save lives. There are very-friendly-to-consumer formulations to make it bullet proof: Prenoxad ® pre-filled injection (syringe contains 5 doses), and Nyxoid ® intranasal (2 devices in a pack, each containing 1 dose). NSWHealth has endorsed such an approach for opioid prescribed and addicted persons under controlled circumstances with education of relevant persons.

  4. mary britton says:

    Has this been done in other countries? Is there any evidence or risk that knowing they have an antedote to side effects that some patients might take the risk of increasing their dose in order to get relief from pain?

  5. Ima Nonymous says:

    The goal of maintaining strict control over narcotic prescribing has become increasingly difficult largely because of the tendency of the Medical Board of Australia to believe complainant patients over practitioners. Drug-seeking patients are well aware of this and that they can easily target an individual practitioner by making a vexatious and malicious complaint. They incur no loss in doing this and are certainly not faced with spending many hours to present their account of events then having to undergo the expense of Board-mandated “re-education” (usually needing to be done twice just to rub it in!) . If you accept this position then you may want to consider how many of the 900 deaths are an indirect result of the Board and its incompetent administrative wing (i.e AHPRA’s) doings.

  6. Anonymous says:

    How are the patients and family going to be trained to draw up and administer Naloxone. Much better to educate about signs opioid toxicity snd to call an ambulance early plus CPR.

Leave a Reply

Your email address will not be published. Required fields are marked *