The co-prescription (co-RX) of naloxone and opioids, along with enhanced mental telehealth services, are helping Tennessee battle the increasing opioid epidemic that’s been triggered by the COVID-19 pandemic, according to state health directors.
“Because naloxone can reverse the effects of opioids by co-prescribing naloxone and opioids, providers can help reduce the chances of a fatal overdose,” Brent Culberson, Assistant Commissioner of Health Licensure and Regulation at the Tennessee Department of Health (TDH), told Health Crisis Alert. “Such harm reduction is an important policy in protecting the lives of Tennesseans.”
The numbers of fatal opioid overdoses across the state are rising due to the coronavirus pandemic, according to local, state, and federal data.
For example, in Shelby County, Tenn., where Memphis is located, an increase in both fatal and nonfatal overdoses have been reported this year, with the Shelby County Health Department in May issuing an overdose spike alert for the 33-day period from April 13 to May 15 with 437 suspected overdose events. Of those, 68 were fatal. Prior to that, the county reported 58 fatal overdoses from April 7 to May 7, the most in a 30-day period since the health department began tracking this data on Jan. 1, 2019.
Western Tennessee U.S. Attorney Dr. Michael Dunavant called the spike “unprecedented.”
Fortunately, Culberson said that the TDH has long counseled prescribers to co-prescribe naloxone to certain at-risk patients who are prescribed opioids, and the department has consulted with the Chronic Pain Guidelines Committee to put out updated guidance for co-prescribing naloxone.
Specifically, the TDH this year incorporated recommendations from the Commissioner’s Committee on Chronic Pain Guidelines to be included as an appendix in the 2019 guidelines regarding the co-prescribing of naloxone. In the appendix, the TDH recommends that healthcare practitioners should incorporate strategies to mitigate risk into any management plan and lists a number of risk factors that may lead to a patient being at a heightened risk of an overdose, according to the guidelines.
“We believe the guidelines, including the appendix, will be a useful tool to guide practitioners in decision making when treating patients,” wrote Tennessee Gov. Bill Lee and TDH Commissioner Dr. Lisa Piercey in a Dec. 27, 2019 letter attached to the updated guidelines.
The Centers for Disease Control and Prevention (CDC) “has also provided guidance about situations when it is appropriate to co-prescribe naloxone and opioids,” pointed out Culberson, who said both the guidance offered by TDH and the CDC have helped educate providers about when co-prescribing is appropriate and has included the minimum standard of care that must be undertaken in prescribing opioids.
“The Tennessee General Assembly has made it easy for patients to have access to naloxone and TDH has worked to ensure widespread access for those patients,” he said.
For instance, according to the CDC guidelines for prescribing opioids — which Tennessee followed in its guidelines — “most experts agreed that clinicians should consider offering naloxone when prescribing opioids to patients at increased risk for overdose, including patients with a history of overdose, patients with a history of substance use disorder, patients taking benzodiazepines with opioids, patients at risk for returning to a high dose to which they are no longer tolerant, and patients taking higher dosages of opioids.”
CDC experts also have noted that naloxone co-prescribing can be facilitated by clinics or practices with resources to provide naloxone training and by collaborative practice models with pharmacists, according to the guidelines.
Encouraging and allowing doctors to co-RX naloxone and opioids is considered one of the safest ways to help patients, particularly as the impacts of the COVID-19 pandemic continue to reverberate around the United States.
“Studies show nearly half of the people in America say the coronavirus pandemic is negatively impacting their mental health, but for those with substance use disorders, this virus can take an even bigger toll,” Amy Murawski, director of the TDH Opioid Response Coordination Office, told Health Crisis Alert.
In fact, the COVID-19 pandemic has made the nationwide opioid crisis worse for people suffering from opioid use disorder due to shelter-in-place orders that have decreased access to treatment; social distancing requirements that may be concealing opioid abuse; and depression from isolation, among other negative impacts.
“The coronavirus pandemic is having detrimental impacts on individuals with opioid use disorder,” Murawski agreed. “Social isolation, decreased access to medications or illicit drug supply, and reduced access to harm-reduction strategies all compound the challenges facing a vulnerable population with comorbid conditions.”
Those who rely on social groups for recovery, said Murawski, now must find other ways to stay healthy, such as through online support sessions.
“On the positive side,” she added, “therapists mediating sessions from their own homes and through telehealth sessions provides a sense of intimacy for patients.”
In addition to the CDC, federal agencies including the Substance Abuse and Mental Health Services Administration (SAMHSA) support co-prescribing naloxone, as do a broad range of stakeholders, including the World Health Organization, state departments of health, and many advocacy groups.