Without opioid painkillers to dull the pain in his knees and other joints, Arnold Wilson could not walk half a block. The 63-year-old former New York nurse has crippling arthritis for which he takes OxyContin twice a day and oxycodone when he needs extra relief.
For the past few years, he’s also kept another drug on hand: naloxone, an overdose reversal drug often referred to by the brand name Narcan.
Although overdose deaths from illicit drugs sold on the street make headlines, the risk of overdose is just as real for patients taking opioids prescribed by their doctor.
“It gives me a sense of relief and security,” said Wilson, who keeps Narcan nasal spray in her car and at home. His pain management physician at Montefiore Medical Center in the Bronx prescribed the opioids in 2013, after an attack of meningitis exacerbated by joint problems Wilson had from two brain aneurysms and multiple strokes. His doctor urged him to start wearing Narcan in 2017.
Naloxone, which begins to reverse an overdose within minutes, is usually given by others. Although he never needed it, Wilson’s 18-year-old daughter knows how to use it. “I told him how to do it, in case I got lethargic,” he said. His girlfriend and friends also know what to do.
A recently enacted New York law aims to ensure that naloxone is available if needed for people like Wilson who are taking prescription opioids.
Under the law, which took effect this summer, physicians must co-prescribe naloxone to certain patients at risk of overdose when writing patients’ first opioid prescriptions each year. Risk factors that would trigger the requirement include taking a high daily dose of an opioid (at least 90 milligram equivalents of morphine, or MME); taking certain other medications, such as sedative hypnotics; or having a history of substance use disorder.
At least 10 other states have similar laws, according to a study by the Network for Public Health Law.
“Sometimes patients, especially if they’ve been on opioids for a long time, don’t understand the risks,” said Dr. Laila Khalid, co-director of the Chronic Pain Clinic at Montefiore Medical Center. The clinic provides free naloxone to patients as part of the state’s Opioid Overdose Prevention Program.
Someone can forget when their last dose was and inadvertently take too much, for example, or have a few extra drinks at a party, Khalid said. Alcohol and certain medications, such as benzodiazepines, amplify the effects of opioids.
“Drug overdose deaths continue to rise, as they have almost every year for more than two decades,” said Emily Einstein, chief of the Science Policy Branch at the National Institute on Drug Abuse. . In 2021, Einstein noted, overdose deaths in the United States topped about 100,000 for the first time, according to interim data from the Centers for Disease Control and Prevention. According to these provisional data, Einstein said, the vast majority of those deaths — more than 80,000 — involved opioids. While mostwere attributable to about 17,000 deaths have involved prescription opioids, including methadone.
Naloxone, available as a nasal spray or injection, is considered safe and causes few side effects. It’s not addictive. The CDC recommends those at risk of overdose take it with them so that a family member or bystander can administer it if needed.
Drug policy experts point to a key statistic that laws like New York’s aim to address: In nearly 40 percent of overdose deaths, another person is present, according to the CDC.
If bystanders had had naloxone, “most of these people wouldn’t have died,” said Corey Davis, director of the Harm Reduction Legal Project at the Network for Public Health Law.
In all states, including New York, pharmacists are authorized to dispense naloxone, often under “standing orders” that allow dispensing without a prescription, usually to those at risk of overdose or able to help a person at risk.
So why ask doctors to write scripts?
According to experts, mandating is more effective than recommending. By requiring doctors to prescribe the drug, more people likely to need naloxone would have it on hand – if they fill the prescription. But there is no guarantee that they will.
A prescription can also help eliminate the lingering stigma of asking for an overdose medication over the counter at the pharmacy.
“It removes the friction points,” Davis said. “You just drove through the window and picked it up.”
In a 2019 analysis, pharmacists in states that required co-prescribing naloxone with opioids filled nearly eight times as many naloxone prescriptions per 100,000 population as those in states that did not.
Missouri doesn’t have a co-prescribing law, but Danielle Muscato’s pain management physician recently suggested she wear Narcan. The 38-year-old civil rights activist, who lives in Colombia, takes the prescription opioid tramadol and several other medications to control her chronic lower back pain. She’s happy to have the nasal spray in her purse, just in case.
“I think it’s a wonderful thing” that people wear it and know how to use it, she said. “I wish that was the norm everywhere.”
Since the New York law took effect, “I’ve definitely seen an increase in prescribers adding naloxone to opioids, especially if it’s a large order,” Ambar Keluskar said. , pharmacy manager of Rossi Pharmacy in Brooklyn.
Patients don’t always understand why they get it, however, said Toni Tompkins, supervising pharmacist at Phelps Hometown Pharmacy in the upstate New York town of Phelps.
A two-dose package of naloxone spray typically costs around $150. The drug is now available in generic form, which may reduce out-of-pocket costs. Most insurers cover it, although patients usually owe a co-pay. Uninsured people can usually get naloxone through public programs.
In New York, private insurers are required to cover naloxone, and Medicaid also covers it, said Monica Pomeroy, spokeswoman for the state health department. The state’s Naloxone Co-pay Assistance Program (N-CAP) covers the cost of copays up to $40 for those with insurance, Pomeroy said. Uninsured people or those with dissatisfied deductibles can get it for free at any of the state’s opioid overdose prevention sites.
In November, the FDA announced that it was considering making naloxone available.
Although offering it over the counter makes the drug easier to obtain, some people worry that insurance won’t cover it. Plus, “if a patient picks it up somewhere and doesn’t receive guidance on how to use it, that could be an inconvenience,” said Anne Burns, vice president of professional affairs at the American Pharmacists Association.
Some professionals believe that naloxone should be dispensed with every opioid prescription, regardless of risk factors. In Rochester, New York, and surrounding Monroe County, this is happening. In 2021, County Executive Adam Bello signed Maisie’s Law, named after a 9-month-old local girl who died after swallowing a methadone pill she found on the kitchen floor of a a neighbour.
“It’s horrible what happened,” said Karl Williams, professor of pharmaceutical law and chairman of the board of directors of the New York State Pharmacists Society. “Maybe it’s a higher level standard that should become law.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.