In this qualitative study by Mueller et al.,1 24 patients prescribed high-dose opioids in a primary care setting were interviewed to understand their attitudes toward receiving naloxone. There are three key findings. First, patients taking high-dose opioids had not been effectively educated about the risk of overdose or about naloxone, and perceived themselves to be at low risk. Second, patients were hesitant to request or accept naloxone due to concern that doing so would indicate that they were abusing their prescribed opioids, which could cause their doctor to taper their medications. Finally, patients would be more accepting of naloxone if their provider approached it in a nonjudgmental way, framing naloxone as a safety measure to have on hand for the “worst-case scenario” that anyone could experience, similar to messages to keep a fire extinguisher in the home.
A qualitative study is appropriate given the lack of prior research on this topic, and the current study builds on the authors’ previous study of primary care providers’ perspectives on naloxone prescribing.2 The earlier study found that primary care providers and staff were concerned that offering naloxone could offend patients or suggest that they believed the patient was abusing opioids. Together, these studies highlight that in the context of heightened concern about opioid abuse, it is the elephant in the room that causes providers and patients to avoid discussions of overdose risk.
Although further research is needed, there are important implications of this work that we should not wait on. Primary care providers prescribing opioids should have ongoing conversations about overdose risk with all their patients, emphasizing that “overdose” may be a misnomer in that it doesn’t only occur when a patient intentionally takes more than the prescribed dose. For example, it can occur with a change in the prescription, after lapses in use, or due to renal failure. Without delay, providers offering naloxone to patients should indeed frame it as a safety valve for patients on opioids, regardless of how they use them. Having these conversations could be a matter of life and death.
References
Mueller SR, Koester S, Glanz JM, Gardner EM, Binswanger IA. 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. 2016. doi:10.1007/s11606-016-3895-8.
Binswanger IA, Koester S, Mueller SR, Gardner EM, Goddard K, Glanz JM. Overdose education and naloxone for patients prescribed opioids in primary care: a qualitative study of primary care staff. J Gen Intern Med. 2015;30:1837. doi:10.1007/s11606-015-3394-3.
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Starrels, J.L. Capsule Commentary on Mueller 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 32, 312 (2017). https://doi.org/10.1007/s11606-016-3941-6
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DOI: https://doi.org/10.1007/s11606-016-3941-6