Dr. Anthony Reyes has to give “a talk” to some of his patients at the Cowlitz Family Health Center. It’s taken some getting used to, the associate medical director said, but most of the patients to whom he offers opioid-reversal drug naloxone are understanding.
Bringing up the possibility of overdose can be uncomfortable for patients, Reyes said, but he’s not accusatory and focuses on safety.
The center trained providers at its seven Cowlitz County medical clinics last month to ask patients who are prescribed opioids if they also want naloxone from a pharmacy, or if they are uninsured, a free kit. The move is part of a statewide push to increase access to the medication, which can reverse the effects of opioid overdosing and save lives. Statewide, 693 people died from opioid overdose last year, according to state health officials.
Some critics say routinely distributing naloxone reinforces bad behavior and emboldens patients to abuse opioids by providing a safety valve of sorts. But, in a county with one of the highest overdose death rates in the state, giving naloxone to patients on opioids for pain relief makes sense, Reyes and others say.
“If you don’t distribute it, it’s not going to save a life,” Reyes said.
The naloxone kits are a plastic bag holding two vials of the medication, two syringes and alcohol swabs. Directions and the prescription information are printed on the front.
The center recently received 2,000 free vials of naloxone from nonprofit Direct Relief. The global organization specifies the medication must be distributed to those who are uninsured or can’t afford it, said Jim Coffee, Family Health Center deputy director.
The center had already been distributing naloxone kits through its syringe exchange for over a year and hopes to save more lives by making the drug even more available, Coffee said.
“It’s like seat belts in a car,” he said. “We want to prevent an accident from becoming a tragedy.”
Family Health Center patient Josh Rongey has seen naloxone in action. The 29-year-old said he got hooked on narcotics after getting his wisdom teeth removed and turned to heroin after he couldn’t get the pills anymore. Rongey said he’s gotten naloxone kits from the center’s syringe exchange and given some to his friends who still use drugs. He said he’s seen naloxone save someone’s life.
“It’s a big game changer for people using opioids,” Rongey said.
Having naloxone on hand makes a difference because otherwise people overdosing would have to wait for an ambulance to arrive, Rongey said.
Guarding against abuse
Dr. Reyes began by offering naloxone to the few patients he has written opioid prescriptions for, then moved on to his patients who have opioid prescriptions from other providers.
One of Reyes’ older patients was grateful for the kit because she worried about her grandchildren getting into her opioid prescriptions, Reyes said. Having the naloxone kit on hand makes her feel safer knowing if something does happen, the reversal drug is immediately available, he said.
“We tell patients to keep (opioids) in a safe place but you can’t know for sure,” Reyes said. “Letting patients have (naloxone) means that if something happens, there is something they can reach for and prevent an overdose death.”
The Family Health Center is the only medical group Coffee is aware of that distributes free naloxone kits in Cowlitz County. Other providers recommend naloxone and people can buy it directly from pharmacies “behind the counter” without a provider’s prescription. Naloxone and Narcan, a nasal-spray version, are available at CVS, Walgreens, Rite Aid and Fred Meyer in Longview.
Wassim Ayoub, Fred Meyer Pharmacy district manager, said the Longview pharmacy doesn’t distribute the drug often. Two doses of injectable naloxone cost $57.99 without any insurance coverage. Narcan is more popular and costs $130 for two doses.
Kaiser Permanente Chief of Addiction Medicine Dr. Bradley Anderson said the group recommends naloxone to all opioid addiction patients and those with opioid prescriptions for chronic pain.
“I believe it should be with all AEDs (defibrillators) in public places,” Anderson said. “It’s a lifesaver and it should be everywhere.”
Coffee said people who may want naloxone either don’t know it is available without a prescription or think that it would be a mark against them if they use their insurance to pay for it. That is not the case, he said, and most insurers cover naloxone or Narcan, including Kaiser Permanente and Premera Blue Cross.
Dian Cooper, Family Health Center CEO, said the organization is not implying that everyone with an opioid prescription will overdose or abuse their pain medication. Naloxone is simply a way of making sure patients are as safe as possible because most overdoses are accidental, she said.
The availability of the kits won’t impact the number of opioid prescriptions written by Family Health Center providers, Cooper said, and opioid prescriptions are decreasing in Cowlitz County (see chart).
The rate of Cowlitz County patients with any opioid prescription is still above the state average, but the rate has dropped from 121.6 per 1,000 people in 2013 to 99 per 1,000 in 2017, according to the state Department of Health. The state rate also decreased in that time, from 97 per 1,000 to 75 per 1,000.
Overdose deaths in Cowlitz County also decreased from 2012 to 2016, from 20 per 100,000 to 14 per 100,000, according to the department. That’s still well above the 2016 state rate of 9.3 per 100,000.
The Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain states providers should consider offering naloxone when there are factors that increase the risk of overdose, such as history of overdose or substance use disorder, higher opioid dose or use of anti-anxiety medications.
Opponents to naloxone and Narcan argue it enables drug users.
Dr. Rich Kirkpatrick of Kirkpatrick Family Care said having naloxone on hand allows recreational users to pursue a higher high, but that he isn’t an expert in recreational drug use.
As for patients with chronic pain, he said the drug isn’t worth the cost unless they have a high risk of overdosing. Kirkpatrick said he would prescribe naloxone to someone with risk factors outlined by the CDC guideline.
According to a 2017 article published in medical journal “Addictive Behaviors,” there is no evidence of heroin users increasing drug use after they received take-home naloxone.
A 2010 peer-reviewed article published in the “Journal of Health Care for the Poor and Underserved” cites two studies that report a decrease in self-reported drug use after getting a naloxone kit.
The article also says there is no data to support the critique that naloxone availability discourages people who overdose from going to the hospital and getting a push to enter treatment. Naloxone kit instructions direct users to call 911 after an overdose.
The Family Health Center may be the first in Cowlitz County to distribute free naloxone kits, but other communities in the state are taking similar steps.
Pharmacist Albert Carbo with Peninsula Community Health Services said naloxone can jump start a conversation about treatment. The Bremerton organization has been pushing to increase naloxone availability in Kitsap and Mason counties for the last couple years. Carbo said when someone has to use the drug, that can be the best time to talk to a patient about seeking treatment.
“If we can save a life, it gives us the opportunity to act upon the next stage,” Carbo said.
Washington State Medical Association executive committee member and Tacoma doctor Nathan Schlicher said he is seeing an increase of similar initiatives across the state.
“These types of programs are exactly what we need to fight the opioid epidemic and get Narcan in the hands of the people who need it the most,” Schlicher said.
Naloxone has been available to first responders and medical professionals for decades, but getting it in the hands of drug users and the people around them has taken longer. Schlicher said barriers include cost and the stigma around having the medication.
Every once and awhile someone is offended by being offered a kit, Schlicher said, but most opioid addicts want to quit. According to a 2018 University of Washington Alcohol and Drug Abuse Institute Study, nearly 80 percent people in the state who use heroin as their main drug were interested in reducing or stopping their opioid use.
For those with opioid prescriptions, the offer of a naloxone kit or prescription can at least open up the conversation among patients and their families about the risks around higher doses of opiates, Schlicher said. The medication can also spark discussions about lowering opioid doses when possible, he said.
“We’re losing many Washingtonians every year to this epidemic. Whether it’s prescription or heroin, it doesn’t matter, we just want people to live through this and get treatment.”