The Opioid Crisis: A Multidisciplinary Perspective on Effective Management - Episode 8
Multidisciplinary expert panel share perspectives on stigmatization and normalization of the conversation about naloxone between clinicians and patients.
Peter Salgo, MD: I want to come back to a basic idea. If naloxone is available over the counter without a prescription—which, by the way, is a great idea—then more people need to know about this.
Jeffrey Bratberg, PharmD, FAPhA: People know, but there is a difference between buying a pregnancy test, buying condoms, and buying whatever you’re buying—diapers, adult diapers, things that people don’t want to buy in a pharmacy. You can buy them, but you have to then deal with the front desk and go. For nicotine replacement therapy, you still have to talk to a pharmacist or a pharmacy tech, and in our research, some are extremely good about recommending naloxone for all those higher-risk prescription opioids or opioid-benzodiazepine combinations. Some have that same, as Theresa said, that same perception of “I don’t want to recommend naloxone.” You have probably heard this from your patients who take opioids appropriately; they do not want to hear they have naloxone. The pharmacist says, “No, I don’t want to give it to you,” so we’re educating pharmacists to say everyone gets it. Our research shows that universal offers work well, and that is what pharmacists and primary care providers need to say. Just offer it to everybody.
Charles Argoff, MD: I’m sorry for jumping again, but an endocrinologist teaching someone how to use insulin would educate the family and people about the signs of hyperglycemia, the signs of hypoglycemia, and what to do or how to have a plan. That is normalized. This is such a biased area of medical care. More people are affected by chronic pain than the combination of heart disease, cancer, and diabetes combined, yet we have so many people biased against simply saying, “I am prescribing this for you to help you. Here are the risk benefits: the good, the bad, the ugly, and here is how you keep safe.” The prescribers are not comfortable with that language.
Joshua Lynch, DO, EMT-P, FAAEM, FACEP: This speaks to the need for a multimodality public health campaign. It is not only about making the patients feel comfortable walking into the pharmacy but also making the pharmacist feel comfortable offering it at the point of dispensing, or even about the doctors or the APPs [advanced practice providers] giving or offering it when they write a prescription.
In Buffalo, New York, we have tried many ways to educate the public, including billboards saying that you can get naloxone at the pharmacy without a prescription. We also have stickers on the window of Walgreens when you walk in the door that say, “Naloxone is available without a prescription—just ask the pharmacist.” We are also putting it either in emergency department discharge papers or on little signs in triage at a patient’s eye level when they are sitting in the triage chair getting screened. There is not 1 way to fix this but making it normal will take probably a generation.
Back to the point of saying patients are ashamed or nervous—either when they’re on opioids or when they have naloxone, I know of many examples, but 1 particular patient stands out. When we were going through her medication history, she was talking about the antihypertensive drugs she takes. She is smiling when she says she is on lisinopril or other things, but she puts her head down when she says that she’s on suboxone [buprenorphine and naloxone]. This is me, a nurse, and a patient in a closed room with no audience or family members. This is how deeply rooted the stigma of looking at the drug user is, and this patient wasn’t even a drug user. This patient had to be on suboxone because there were a whole bunch of problems in the past. It is an internal stigma. Even the patient is embarrassed about it. These are deep-rooted things that require approaches from all different angles to change anything.
Jeremy Adler, DMSc, PA-C, DFAAPA: There is also a significant way that naloxone has been framed that has interfered with its utilization and uptick. Going back to the example of an EpiPen, there is this idea that it is an antidote for bee sting anaphylaxis. If you use that analogy, then the essence of the issue is that we are prescribing bee stings with our opioids and giving them the antidote with naloxone, which does not make a lot of sense. Just stop giving the opioid, and they do not need the naloxone. That is the mindset. Therefore, if they’re so at risk that you have to prescribe naloxone, then why are you prescribing in the first place?
I’ve completely reframed how I discuss naloxone with patients. That is, I say having an opioid in the home increases the risk of an accidental overdose. That may not be because somebody is doing something inappropriate; they may take a dose, forget they took it, and take it again. They may take it thinking they took something else. We know from the diversion data that most misusers get it without a prescription from a patient who has a prescription. Our patient may become the rescuer. I use the example of placing a fire extinguisher in a kitchen. You do not put your fire extinguisher there because you plan to build a bonfire on your stove. You put it there in case there is an accident. This is about risk prevention; the more naloxone is out, the more it will likely be where it is needed. It is not that your patient is doing something inappropriate or wrong when you offer them a naloxone.
The way health care and community need to think about this has to be repositioned and reframed to see its utilization in this space and to create normalization.
Theresa Mallick-Searle, MS, RN-BC, ANP-BC: We need to normalize it, absolutely.
Peter Salgo, MD: There is also, it seems to me, some wishful thinking among practitioners—
“That is other people’s patient population. Not mine. I have the good patients, and my patients do not need naloxone.” Nothing could be further from the truth. Drugs are drugs; overdoses are overdoses, inadvertent or otherwise. Naloxone is lifesaving, period. Isn’t that the message? It is very simple.
Transcript Edited for Clarity