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Opioid Overdose TOOLKIT:
Information for Prescribers
TABLE OF CONTENTS
INFORMATION FOR PRESCRIBERS
OPIOID OVERDOSE
3
TREATING OPIOID OVERDOSE
7
LEGAL AND LIABILITY CONSIDERATIONS
9
CLAIMS CODING AND BILLING
9
RESOURCES FOR PRESCRIBERS
9
ACKNOWLEDGMENTS, ETC.
11
n Acknowledgments
n Disclaimer
n PublicDomainNotice
n ElectronicAccessandCopiesofPublication
n RecommendedCitation
n OriginatingOffice
Also see the other components of this Toolkit:
.FactsforCommunityMembers
.FiveEssentialStepsforFirstResponders
.SafetyAdviceforPatients&FamilyMembers
.RecoveringfromOpioidOverdose:
ResourcesforOverdoseSurvivors&FamilyMembers
INFORMATION FOR PRESCRIBERS
O
pioidoverdoseisamajorpublichealthproblem,accountingfor
almost17,000deathsayearintheUnitedStates[1].Overdose
involvesbothmalesandfemalesofallages,ethnicities,and
demographicandeconomiccharacteristics,andinvolvesbothillicit
opioidssuchasheroinand,increasingly,prescriptionopioidanalgesics
suchasoxycodone,hydrocodone,fentanylandmethadone[2].
Physiciansandotherhealthcareproviderscanmakeamajor
contributiontowardreducingthetollofopioidoverdosethroughthe
caretheytakeinprescribingopioidanalgesicsandmonitoringpatients’
response,aswellastheiracuityinidentifyingandeffectivelyaddressing
opioidoverdose.FederallyfundedCMEcoursesareavailableatno
chargeatwww.OpioidPrescribing.com(fivecoursesfundedbythe
SubstanceAbuseandMentalHealthServicesAdministration)andon
MedScape(twocoursesfundedbytheNationalInstituteonDrugAbuse).
OPIOID OVERDOSE
Theriskofopioidoverdosecanbeminimizedthroughadherencetothe
followingclinicalpractices,whicharesupportedbyaconsiderablebody
ofevidence[3-6].
ASSESS THE PATIENT. Obtainingahistoryofthepatient’spastuseof
drugs(eitherillicitdrugsorprescribedmedicationswithabusepotential)
isanessentialfirststepinappropriateprescribing.Suchahistoryshould
includeveryspecificquestions.Forexample:
n Inthepast6months,haveyoutakenanymedicationstohelpyou
calmdown,keepfromgettingnervousorupset,raiseyourspirits,
makeyoufeelbetter,andthelike?
n Haveyoubeentakinganymedicationstohelpyousleep?Haveyou
beenusingalcoholforthispurpose?
n Haveyouevertakenamedicationtohelpyouwithadrugor
alcoholproblem?
n Haveyouevertakenamedicationforanervousstomach?
n Haveyoutakenamedicationtogiveyoumoreenergyortocutdown
onyourappetite?
Thepatienthistoryalsoshouldincludequestionsaboutuseofalcohol
andover-the-counter(OTC)preparations.Forexample,theingredients
inmanycommoncoldpreparationsincludealcoholandothercentral
nervoussystem(CNS)depressants,sotheseproductsshouldnotbe
usedincombinationwithopioidanalgesics.
Positiveanswerstoanyofthesequestionswarrantfurtherinvestigation.
TAKE SPECIAL PRECAUTIONS
WITH NEW PATIENTS. Manyexperts
recommendthatadditionalprecautions
betakeninprescribingfornewpatients
[5,6].Thesemightinvolvethefollowing:
1. Assessment:Inadditiontothepatient
historyandexamination,thephysicianshoulddeterminewhohasbeen
caringforthepatientinthepast,what
medicationshavebeenprescribed
andforwhatindications,andwhat
substances(includingalcohol,illicit
drugsandOTCproducts)thepatient
hasreportedusing.Medicalrecords
shouldbeobtained(withthepatient’s
consent).
2. Emergencies:Inemergencysituations,
thephysicianshouldprescribethe
smallestpossiblequantity,typicallynot
exceedinga3days’supplyofanopioid
analgesicandarrangeforareturn
visitthenextday.Ataminimum,the
patient’sidentityshouldbeverifiedby
askingforproperidentification.
3. Limit quantities:Innon-emergency
situations,onlyenoughofanopioid
analgesicshouldbeprescribedto
meetthepatient’sneedsuntilthe
nextappointment.Thepatientshould
bedirectedtoreturn to the officefor
additionalprescriptions,astelephone
ordersdonotallowthephysicianto
reassessthepatient’scontinuedneed
forthemedication.
INFORMATION FOR PRESCRIBERS
STATE PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPs)
have emergedas akeystrategyforaddressingthe misuseandabuse
ofprescriptionopioids and thuspreventingopioid overdosesand
deaths.Specifically, prescriberscan checktheirstate’sPDMPdatabase
to determinewhetherapatientisfillingthe prescriptionsprovidedand/
orobtainingprescriptionsforthe sameorsimilar drug from multiple
physicians.
Whilem a n y statesnowhaveoperationalPDMPs,the programs
differfrom stateto stateintermsofthe exactinformationcollected,how
soon thatinformationisavailable to physicians,and whomay access
the data.Therefore,informationaboutthe programinaparticularstate
isbestobtaineddirectlyfrom the PDMPorfrom thestate boardof
medicineorpharmacy.
SELECT AN APPROPRIATE MEDICATION. Rationaldrugtherapy
demandsthattheefficacyandsafetyofallpotentiallyuseful
medicationsbereviewedfortheirrelevancetothepatient’sdiseaseor
disorder[3,6].
Whenanappropriatemedicationhasbeenselected,thedose,
schedule,andformulationshouldbedetermined.Thesechoicesoften
arejustasimportantinoptimizingpharmacotherapyasthechoiceof
medicationitself.Decisionsinvolve(1)dose(basednotonlyonage
andweightofthepatient,butalsoonseverityofthedisorder,possible
loading-doserequirement,andthepresenceofpotentiallyinteracting
drugs);(2)timingofadministration(suchasabedtimedosetominimize
problemsassociatedwithsedativeorrespiratorydepressanteffects);(3)
routeofadministration(chosentoimprovecompliance/adherenceas
wellastoattainpeakdrugconcentrationsrapidly);and(4)formulation
(e.g.,selectingapatchinpreferencetoatablet,oranextended-release
productratherthananimmediate-releaseformulation).
Additionalsafeguardsarerecommendedbeforeprescribinganopioid
analgesic.Forexample,evenwhensoundmedicalindicationshavebeen
established,physicianstypicallyconsiderthreeadditionalfactorsbefore
decidingtoprescribe[3,6]:
1. Theseverity of symptoms,intermsofthepatient’sabilityto
accommodatethem.Reliefofsymptomsisalegitimategoalofmedicalpractice,butusingopioidanalgesicsrequirescaution.
2. Thepatient’sreliability in taking medications,notedthrough
observationandcarefulhistory-taking.Thephysicianshouldassessa
patient’shistoryofandriskfactorsfordrugabusebeforeprescribing
anypsychoactivedrugandweighthebenefitsagainsttherisks.The
likelydevelopmentofphysicaldependenceinpatientsonlong-term
opioidtherapyshouldbemonitoredthroughperiodiccheck-ups.
3. Thedependence-producing potential of the medication.Thephysician
shouldconsiderwhetheraproductwith
lesspotentialforabuse,orevenanondrugtherapy,wouldprovideequivalent
benefits.Patientsshouldbewarned
aboutpossibleadverseeffectscaused
byinteractionsbetweenopioidsand
othermedicationsorillicitsubstances,
includingalcohol.
Atthetimeadrugisprescribed,
patientsshouldbeinformedthatitis
illegaltosell,giveaway,orotherwiseshare
theirmedicationwithothers,including
familymembers.Thepatient’sobligation
extendstokeepingthemedicationina
lockedcabinetorotherwiserestricting
accesstoitandtosafelydisposingof
anyunusedsupply(visithttp://www.fda.
gov/ForConsumers/ConsumerUpdates/
ucm101653.htmforadvicefromthe
FDAonhowtosafelydisposeofunused
medications).
EDUCATE THE PATIENT AND OBTAIN
INFORMED CONSENT.Obtaining
informedconsentinvolvesinformingthe
patientabouttherisksandbenefitsofthe
proposedtherapyandoftheethicaland
legalobligationssuchtherapyimposes
onboththephysicianandpatient[6].
Suchinformedconsentcanservemultiple
purposes:(1)itprovidesthepatientwith
informationabouttherisksandbenefits
ofopioidtherapy;(2)itfostersadherence
tothetreatmentplan;(3)itlimitsthe
potentialforinadvertentdrugmisuse;
and(4)itimprovestheefficacyofthe
treatmentprogram.
Patienteducationandinformedconsent
shouldspecificallyaddressthepotential
forphysicaldependenceandcognitive
impairmentassideeffectsassociatedwith
INFORMATION FOR PRESCRIBERS
opioidanalgesics.Otherissuesthatshouldbeaddressedintheinformed
consentortreatmentagreementincludethefollowing[6]:
n Theagreementinstructsthepatienttostoptakingallotherpainmedications,unlessexplicitlytoldtocontinuebythephysician.Suchastatementreinforcestheneedtoadheretoasingletreatmentregimen.
n Thepatientagreestoobtaintheprescribedmedicationfromonlyone
physicianand,ifpossible,fromonedesignatedpharmacy.
n Thepatientagreestotakethemedicationonlyasprescribed(forsome
patients,itmaybepossibletoofferlatitudetoadjustthedoseas
symptomsdictate).
n Theagreementmakesitclearthatthepatientisresponsibleforsafeguardingthewrittenprescriptionandthesupplyofmedications,and
arrangingrefillsduringregularofficehours.Thisresponsibilityincludes
planningaheadsoasnottorunoutofmedicationduringweekendsor
vacationperiods.
n Theagreementspecifiestheconsequencesforfailingtoadheretothe
treatmentplan,whichmayincludeweaninganddiscontinuationof
opioidtherapyifthepatient'sactionscompromisehisorhersafety.
Bothpatientandphysicianshouldsigntheinformedconsent
agreement,andacopyshouldbeplacedinthepatient'smedicalrecord.
Italsoishelpfultogivethepatientacopyoftheagreementtocarrywith
himorher,todocumentthesourceandreasonforanycontrolleddrugs
inhisorherpossession.Somephysiciansprovidealaminatedcardthat
identifiestheindividualasapatientoftheirpractice.Thisishelpfulto
otherphysicianswhomayseethepatientandintheeventthepatientis
seeninanemergencydepartment.
EXECUTE THE PRESCRIPTION ORDER. Carefulexecutionofthe
prescriptionordercanpreventmanipulationbythepatientorothers
intentonobtainingopioidsfornon-medicalpurposes.Forexample,federal
lawrequiresthatprescriptionordersforcontrolledsubstancesbesigned
anddatedonthedaytheyareissued.Alsounderfederallaw,every
prescriptionordermustincludeatleastthefollowinginformation:
Nameandaddressofthepatient
Name,addressandDEAregistrationnumberofthephysician
Signatureofthephysician
Nameandquantityofthedrugprescribed
Directionsforuse
Refillinformation
Effectivedateifotherthanthedateonwhichtheprescription
waswritten
Manystatesimposeadditional
requirements,whichthephysician
candeterminebyconsultingthestate
medicallicensingboard.Inaddition,
therearespecialfederalrequirements
fordrugsindifferentschedulesofthe
federalControlledSubstancesAct
(CSA),particularlythoseinSchedule
II,wheremanyopioidanalgesics
areclassified.
Blankprescriptionpads,aswell
asinformationsuchasthenamesof
physicianswhorecentlyretired,leftthe
state,ordiedallcanbeusedtoforge
prescriptions.Therefore,itisasound
practicetostoreblankprescriptionsin
asecureplaceratherthanleavingthem
inexaminingrooms.
NOTE:Thephysicianshouldimmediately
reportthetheftorlossofprescriptionblanks
tothenearestfieldofficeofthefederalDrug
EnforcementAdministrationandtothestate
boardofmedicineorpharmacy.
MONITOR THE PATIENT’S RESPONSE
TO TREATMENT. Properprescription
practicesdonotendwhenthepatient
receivesaprescription.Planstomonitor
fordrugefficacyandsafety,compliance,
andpotentialdevelopmentoftolerance
mustbedocumentedandclearly
communicatedtothepatient[3].
Subjectivesymptomsareimportant
inmonitoring,asareobjectiveclinical
signs(suchasbodyweight,pulserate,
temperature,bloodpressure,andlevels
ofdrugmetabolitesinthebloodstream).
Thesecanserveasearlysignsof
therapeuticfailureorunacceptable
adversedrugreactionsthatrequire
modificationofthetreatmentplan.
Askingthepatienttokeepalogof
signsandsymptomsgiveshimorhera
senseofparticipationinthetreatment
INFORMATION FOR PRESCRIBERS
programandfacilitatesthephysician’sreview
oftherapeuticprogressandadverseevents.
Simplyrecognizingthepotentialfornonadherence,especiallyduringprolonged
treatment,isasignificantsteptowardimproving
medicationuse[7].Stepssuchassimplifying
thedrugregimenandofferingpatienteducation
alsoimproveadherence,asdophonecallsto
patients,homevisitsbynursingpersonnel,
convenientpackagingofmedication,and
periodicurinetestingfortheprescribedopioid
aswellasanyotherrespiratorydepressant.
Finally,thephysicianshouldconveytothe
patientthroughattitudeandmannerthatany
medication,nomatterhowhelpful,isonlypart
ofanoveralltreatmentplan.
Whenthephysicianisconcernedabout
thebehaviororclinicalprogress(orthelack
thereof)ofapatientbeingtreatedwithan
opioidanalgesic,itusuallyisadvisabletoseek
aconsultationwithanexpertinthedisorderfor
whichthepatientisbeingtreatedandanexpert
inaddiction.Physiciansplacethemselvesat
riskiftheycontinuetoprescribingopioidsin
theabsenceofsuchconsultations[6].
CONSIDER PRESCRIBING NALOXONE
ALONG WITH THE PATIENT’S INITIAL
OPIOID PRESCRIPTION. Withproper
education,patientsonlong-termopioidtherapy
andothersatriskforoverdosemaybenefit
fromhavinganaloxonekittouseintheevent
ofoverdose[8].
Patientswhoarecandidatesforsuchkits
includethosewhoare:
n Takinghighdosesofopioidsforlong-term
managementofchronicmalignantornonmalignantpain.
n Dischargedfromemergencymedicalcarefollowingopioid
intoxicationorpoisoning.
n Athighriskforoverdosebecauseofalegitimatemedicalneed
foranalgesia,coupledwithasuspectedorconfirmedhistoryof
substanceabuse,dependence,ornon-medicaluseofprescriptionorillicitopioids.
n Completingmandatoryopioiddetoxificationorabstinence
programs.
n Recentlyreleasedfromincarcerationandapastuserorabuser
ofopioids(andpresumablywithreducedopioidtoleranceand
highriskofrelapsetoopioiduse).
Italsomaybeadvisabletosuggestthattheat-riskpatient
createan“overdoseplan”tosharewithfriends,partnersand/or
caregivers.Suchaplanwouldcontaininformationonthesigns
ofoverdoseandhowtoadministernaloxoneorotherwiseprovide
emergencycare(asbycalling911).
DECIDE WHETHER AND WHEN TO END OPIOID THERAPY.
Certainsituationsmaywarrantimmediatecessationofprescribing.
Thesegenerallyoccurwhenout-of-controlbehaviorsindicatethat
continuedprescribingisunsafeorcausingharmtothepatient[3].
Examplesincludealteringorsellingprescriptions,accidentalor
intentionaloverdose,multipleepisodesofrunningoutearly(dueto
excessiveuse),doctorshopping,orthreateningbehavior.
Whensucheventsarise,itisimportanttoseparatethepatient
asapersonfromthebehaviorscausedbythediseaseofaddiction,
asbydemonstratingapositiveregardforthepersonbutno
tolerancefortheaberrantbehaviors.
Theessentialstepsareto(1)stopprescribing,(2)tellthe
patientthatcontinuedprescribingisnotclinicallysupportable
(andthusnotpossible),(3)urgethepatienttoacceptareferral
forassessmentbyanaddictionspecialist,(4)educatethepatient
aboutsignsandsymptomsofspontaneouswithdrawalandurge
thepatienttogototheemergencydepartmentifsymptomsoccur,
and(5)assurethepatientthatheorshewillcontinuetoreceive
careforthepresentingsymptomsorcondition[6].
n Receivingrotatingopioidmedication
regimens(andthusatriskforincomplete
cross-tolerance).
INFORMATION FOR PRESCRIBERS
Identificationofapatientwhoisabusingaprescribedcontrolled
drugpresentsamajortherapeuticopportunity.Thephysicianshould
haveaplanformanagingsuchapatient,typicallyinvolvingworkwith
thepatientandthepatient’sfamily,referraltoanaddictionexpertfor
assessmentandplacementinaformaladdictiontreatmentprogram,
long-termparticipationina12-Stepmutualhelpprogramsuchas
NarcoticsAnonymous,andfollow-upofanyassociatedmedicalor
psychiatriccomorbidities[3].
Inallcases,patientsshouldbegiventhebenefitofthephysician’s
concernandattention.Itisimportanttorememberthatevendrugseekingpatientsoftenhaveveryrealmedicalproblemsthatdemand
anddeservethesamehigh-qualitymedicalcareofferedtoany
patient[3,6].
TREATING OPIOID OVERDOSE
Inthetimeittakesforanoverdosetobecomefatal,itispossibleto
reversetherespiratorydepressionandothereffectsofopioidsthrough
respiratorysupportandadministrationoftheopioidantagonist
naloxone(Narcan)[9].NaloxoneisapprovedbytheFDAandhasbeen
usedfordecadestoreverseoverdoseandresuscitateindividualswho
haveoverdosedonopioids.
Thesafetyprofileofnaloxoneisremarkablyhigh,especiallywhen
usedinlowdosesandtitratedtoeffect[8,9].Ifgiventoindividuals
whoarenotopioid-intoxicatedoropioid-dependent,naloxone
producesnoclinicaleffects,evenathighdoses.Moreover,whilerapid
opioidwithdrawalintolerantpatientsmaybeunpleasant,itisnot
typicallylife-threatening.
Naloxoneshouldbepartofanoverallapproachtoopioidoverdose
thatincorporatesthefollowingsteps.
SignsofOVERMEDICATION,whichmay
progresstooverdose,include[3]:
n Unusualsleepinessordrowsiness
n Mentalconfusion,slurredspeech,
intoxicatedbehavior
n Sloworshallowbreathing
n Pinpointpupils
n Slowheartbeat,lowbloodpressure
n Difficultywakingtheindividual
fromsleep
Becauseopioidsdepressrespiratory
functionandbreathing,onetelltalesignof
anindividualinacriticalmedicalstateisthe
“deathrattle.”Oftenmistakenforsnoring,
the“deathrattle”isanexhaledbreathwith
averydistinct,laboredsoundcomingfrom
thethroat.Itindicatesthatemergency
resuscitationisneededimmediately[8].
RECOGNIZE THE SIGNS OF OVERDOSE. Anopioidoverdose
requiresrapiddiagnosis.Themostcommonsignsofoverdose
include[3]:
SUPPORT RESPIRATION. Supporting
respirationisthesinglemostimportant
interventionforopioidoverdoseand
maybelife-savingonitsown.Ideally,
individualswhoareexperiencingopioid
overdoseshouldbeventilatedwith100%
oxygenbeforenaloxoneisadministeredto
reducetheriskofacutelunginjury[3,8].
Insituationswhere100%oxygenisnot
available,rescuebreathingcanbevery
effectiveinsupportingrespiration[8].Rescue
breathinginvolvesthefollowingsteps:
n Paleandclammyface
n Verifythattheairwayisclear.
n Limpbody
n Withonehandonthepatient'schin,tilt
theheadbackandpinchthenoseclosed.
n Fingernailsorlipsturningblue/purple
n Placeyourmouthoverthepatient's
mouthtomakeasealandgive2slow
breaths(thepatient'schestshouldrise,
butnotthestomach).
n Vomitingorgurglingnoises
n Cannotbeawakenedfromsleeporisunabletospeak
n Verylittleornobreathing
n Veryslowornoheartbeat
n Followupwithonebreathevery
5seconds.
INFORMATION FOR PRESCRIBERS
ADMINISTER NALOXONE.Naloxone(Narcan)shouldbe
giventoanypatientwhopresentswithsignsofopioidoverdose,
orwhenoverdoseissuspected[8].Naloxonecanbegivenby
intramuscularorintravenousinjectionevery2to3minutes[8-10].
Themostrapidonsetofactionisachievedbyintravenous
administration,whichisrecommendedinemergencysituations
[9].Intravenousadministrationgenerallyisusedwithpatients
whohavenohistoryofopioiddependence.Opioid-naivepatients
maybegivenstartingdosesofupto2mgwithoutconcernfor
triggeringwithdrawalsymptoms[8].
Theintramuscularrouteofadministrationmaybemore
suitableforpatientswithahistoryofopioiddependencebecause
itprovidesasloweronsetofactionandaprolongedduration
ofeffect,whichmayminimizerapidonsetofwithdrawal
symptoms[8].
Pregnant patients.Naloxonecansafelybeusedtomanageopioid
overdoseinpregnantwomen.Thelowestdosetomaintain
spontaneousrespiratorydriveshouldbeusedtoavoidtriggering
acuteopioidwithdrawal,whichmaycausefetaldistress[8].
MONITOR THE PATIENT’S RESPONSE. Patientsshouldbe
monitoredforre-emergenceofsignsandsymptomsofopioid
toxicityforatleast4hoursfollowingthelastdoseofnaloxone
(however,patientswhohaveoverdosedonlong-actingopioids
requiremoreprolongedmonitoring)[8].
Mostpatientsrespondtonaloxonebyreturningto
spontaneousbreathing,withmildwithdrawalsymptoms[8].
Theresponsegenerallyoccurswithin3to5minutesofnaloxone
administration.(Rescuebreathingshouldcontinuewhilewaiting
forthenaloxonetotakeeffect.)
Thedurationofeffectofnaloxoneis30to90minutes.
Patientsshouldbeobservedafterthattimeforre-emergence
ofoverdosesymptoms.Thegoalofnaloxonetherapyshould
berestorationofadequatespontaneousbreathing,butnot
necessarilycompletearousal[8-10].
More than one dose of naloxone may be required to revive
the patient. Those who have taken longer-acting opioids may
require further intravenous bolus doses or an infusion of
naloxone [8]. Therefore,itisessentialtogetthepersontoan
emergencydepartmentorothersourceofacutecareasquickly
aspossible,evenifheorsherevivesaftertheinitialdoseof
naloxoneandseemstofeelbetter.
SIGNS OF OPIOID WITHDRAWAL:Withdrawal
triggeredbynaloxonecanfeelunpleasant.As
aresult,somepersonsbecomeagitatedor
combativewhenthishappensandneedhelpto
remaincalm.
Thesignsandsymptomsofopioidwithdrawal
inanindividualwhoisphysicallydependenton
opioidsmayinclude,butarenotlimitedto,the
following:bodyaches,diarrhea,tachycardia,fever,
runnynose,sneezing,piloerection,sweating,
yawning,nauseaorvomiting,nervousness,
restlessnessorirritability,shiveringortrembling,
abdominalcramps,weakness,andincreased
bloodpressure[9].Withdrawalsyndromesmay
beprecipitatedbyaslittleas0.05to0.2mg
intravenousnaloxoneinapatienttaking24mg
perdayofmethadone.
Inneonates,opioidwithdrawalalsomay
produceconvulsions,excessivecrying,and
hyperactivereflexes[9].
NALOXONE-RESISTANT PATIENTS:Ifapatient
doesnotrespondtonaloxone,analternative
explanationfortheclinicalsymptomsshouldbe
considered.Themostlikelyexplanationisthat
thepersonisnotoverdosingonanopioidbut
rathersomeothersubstanceormayevenbe
experiencinganon-overdosemedicalemergency.
Apossibleexplanationtoconsideriswhether
theindividualhasoverdosedonbuprenorphine,
along-actingopioidpartialagonist.Because
buprenorphinehasahigheraffinityforthe
opioidreceptorsthandootheropioids,naloxone
maynotbeeffectiveatreversingtheeffectsof
buprenorphine-inducedopioidoverdose[8].
Inallcases,supportofventilation,oxygenation,
andbloodpressureshouldbesufficienttoprevent
thecomplicationsofopioidoverdoseandshould
begiventhehighestpriorityifthepatient’s
responsetonaloxoneisnotprompt.
NOTE:Allnaloxoneproductshaveanexpirationdate.
Itisimportanttochecktheexpirationdateandobtain
replacementnaloxoneasneeded.
INFORMATION FOR PRESCRIBERS
LEGAL AND LIABILITY
CONSIDERATIONS
RESOURCES FOR
PRESCRIBERS
Health care professionals who are concerned about legal risks
associatedwithprescribingnaloxonemaybereassuredbythefact
thatprescribingnaloxonetomanageopioidoverdoseisconsistent
withthedrug’sFDA-approvedindication,resultinginnoincreased
liabilitysolongastheprescriberadherestogeneralrulesof
professionalconduct.Statelawsandregulationsgenerallyprohibit
physiciansfromprescribingadrugsuchasnaloxonetoathird
party,suchasacaregiver.(Illinois,Massachusetts,NewYork,and
WashingtonStatearetheexceptionstothisgeneralprinciple.)More
informationonstatepoliciesisavailableatwww.prescribetoprevent.
org/ or from individual state medical boards.
Additional information on prescribing
opioidsforchronicpainisavailableatthe
followingwebsites:
CLAIMS CODING AND BILLING
Mostprivatehealthinsuranceplans,Medicare,andMedicaidcover
naloxoneforthetreatmentofopioidoverdose,butpoliciesvaryby
state.Thecostoftake-homenaloxoneshouldnotbeaprohibitive
factor.Notallcommunitypharmaciesstocknaloxoneroutinelybut
canalwaysorderit.Ifyouarecaringforalargepatientpopulation
likelytobenefitfromnaloxoneyoumaywishtonotifythepharmacy
whenyouimplementnaloxoneprescribingasaroutinepractice.
ThecodesforScreening,BriefIntervention,andReferralto
Treatment(SBIRT)canbeusedtobilltimeforcounselingapatient
abouthowtorecognizeoverdoseandhowtoadministernaloxone.
BillingcodesforSBIRTareasfollows:
CommercialInsurance:CPT99408(15to30minutes)
Medicare:G0396(15to30minutes)
Medicaid:H0050(per15minutes)
www.opioidprescribing.com. Sponsoredby
theBostonUniversitySchoolofMedicine,
withsupportfromSAMHSA,thissite
presentscoursemodulesonvariousaspects
ofprescribingopioidsforchronicpain.To
viewthelistofcoursesandtoregister,goto
http://www.opioidprescribing.com/overview.
CMEcreditsareavailableatnocharge.
www.pcss-o.org or www.pcssb.org.
SponsoredbytheAmericanAcademyof
AddictionPsychiatryincollaborationwith
otherspecialtysocietiesandwithsupport
fromSAMHSA,thePrescriber’sClinical
SupportSystemoffersmultipleresources
relatedtoopioidprescribingandthe
diagnosisandmanagementofopioid
usedisorders.
www.medscape.com. Two course modules
sponsoredbytheNationalInstituteon
DrugAbuseandpostedonMedScapecan
beaccessedathttp://www.medscape.
org/viewarticle/770687 and http://www.
medscape.org/viewarticle/770440.CME
creditsareavailable.
INFORMATION FOR PRESCRIBERS
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history.J Pain Symptom Manage.2004;28:250.
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10
Acknowledgments
This publication was prepared for the Substance Abuse and Mental Health Services
Administration (SAMHSA) by the Association of State and Territorial Health Officials,
in cooperation with Public Health Research Solutions, under contract number
10-233-00100 with SAMHSA, U.S. Department of Health and Human Services (HHS).
LCDR Brandon Johnson, M.B.A., served as the Government Project Officer.
Disclaimer
The views, opinions, and content of this publication are those of the authors and do
notnecessarilyreflecttheviews,opinions,orpoliciesofSAMHSAorHHS.
Public Domain Notice
Allmaterialsappearinginthisvolumeexceptthosetakendirectlyfromcopyrighted
sourcesareinthepublicdomainandmaybereproducedorcopiedwithout
permissionfromSAMHSAortheauthors.Citationofthesourceisappreciated.
However,thispublicationmaynotbereproducedordistributedforafeewithout
the specific, written authorization of the Office of Communications, SAMHSA, HHS.
Electronic Access and Copies of Publication
This publication may be ordered from SAMHSA’s Publications Ordering Web page at
www.store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727)
(EnglishandEspañol).
Recommended Citation
SubstanceAbuseandMentalHealthServicesAdministration.SAMHSAOpioid
OverdosePreventionToolkit:InformationforPrescribers.HHSPublication
No.(SMA)13-4742.Rockville,MD:SubstanceAbuseandMentalHealthServices
Administration, 2013.
Originating Office
Division of Pharmacologic Therapies, Center for Substance Abuse Treatment,
Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road,
Rockville, MD 20857.
11
HHS Publication No. (SMA) 13-4742
Printed 2013