Clinical

Naloxone: Difficult conversations about a potential lifesaver

Assessing an opioid-safety intervention


 

New tools to help minimize the risk of opioid-related adverse events are becoming more widely available, although providers are still struggling over how best to implement them.

A recent study by Shane Mueller, MSW, and Ingrid Binswanger, MD, at Kaiser Permanente Colorado Institute for Health Research, Denver, for instance, found that doctors are frequently uncomfortable prescribing the opioid antagonist naloxone to counteract a potential overdose.1

Shane Mueller is a project manager at the Kaiser Permanente Colorado Institute for Health Research.

Shane Mueller

The discomfort may prevent doctors from having difficult but necessary conversations about the medication’s risks and benefits, says Mr. Mueller, a project manager at the institute. For their part, patients recognized the utility of naloxone but were afraid that accepting a prescription for it would suggest that they were misusing their opioid medication.

Although much of the research was conducted in outpatient settings, the researchers say several lessons may be translated to the hospital readily. “Patients were really willing to embrace the idea of naloxone when it was framed to be used in a worst-case scenario,” Mr. Mueller said; some providers, for example, compared it to having a fire extinguisher in the house. “I think one patient said, ‘You know, I don’t plan on starting a fire in my kitchen, but it’s good to have there just in case something goes wrong.’ ”

Another important lesson, Mr. Mueller said, is to consider multiple factors that might heighten the overdose risk, such as a change in the prescription or a medical condition like renal failure. Including those considerations in a conversation might help destigmatize the topic and help patients who are concerned that they might be perceived as misusing the medication.

Dr. Ingrid Binswanger is a hospitalist in Denver.

Dr. Ingrid Binswanger

The study suggested that, when providers adopted a nonjudgmental and better-safe-than-sorry tone, patients were much more willing to accept the message and the naloxone prescription. “It seemed like patients were also more amenable to receiving naloxone when they thought about other people in their home who could potentially experience an overdose just by having medication in the home,” said Dr. Binswanger, a senior investigator at Kaiser Permanente. Framing the prescription as protection for loved ones, then, also can be effective.

Ideally, opioid-safety interventions should be more patient centered, emphasizing safer home storage to prevent secondary exposures and educating patients fully about the medication’s downsides, she said. “They may have been on them a long time but never been fully informed of the risks,” she said. Among her group’s future research goals, Dr. Binswanger hopes to investigate how best to communicate such risks to patients.

References

1. Mueller SR, Koester S, Glanz JM, et al. Attitudes toward naloxone prescribing in clinical settings: A qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017 March;32(3):277-83.

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