As healthcare professionals it is important to advocate for ethical, responsible (safe), and quality care for patients. Involvement of the patient and their caregivers is essential to ensure the wishes of the patient are fulfilled. The prioritization of any one aspect of care should not be preceded by another. So, with respect to providing the best care for patients, let’s talk about the use of naloxone in the setting of hospice.
Hospice is an elective treatment approach for terminally ill patient who no longer wish to receive treatment directed at curing or managing their illness.1 The Social Security Act (SSA) defines “terminally ill” as “[the] individual has a medical prognosis that the individual’s life expectancy is 6 months or less.”2 These patients are cared for under palliative care principles, one principle of which is defined by the World Health Organization (WHO) as, “[palliative care] intends neither to hasten or postpone death.”3 This represents an important aspect of care for this population, because despite the life expectancy of any patient, safety and the concept of ‘do no harm’ remain essential principles for guiding treatment. Recently, prescribing of naloxone prescriptions for patients at risk for opioid induced respiratory depression (OIRD), has become a hot topic for debate amongst the hospice and palliative care community.
Naloxone is a mu opioid receptor antagonist, administered via injection or intranasal spray, for use in the setting of either intentional OR accidental opioid overdose to reverse the effects of OIRD.4,5,6 Untreated, OIRD can result in death or brain damage due to insufficient oxygen supply to the brain. OIRD is not a spontaneous part of the natural progression of life. The possession of a tool (naloxone) that can help combat the risks associated with a medication is a strong asset with considerable safety benefits.5-8 When considering the use of naloxone in the setting of hospice, safety should always be a priority.
Several organizations including The American Medical Association (AMA) opioid task force, Center for Disease Control, the World Health Organization, to name a few, recommended practices for opioid prescribing and naloxone co-prescribing in the setting of chronic pain.7,8,9 Notably, these guidelines and recommendations were not formulated for hospice or palliative care patients, but it is important to understand some of the general safety guidance that is available when considering the overall care of patients.
The CDC, U.S. Surgeon General, and AMA Opioid Task Force, recommend the regular evaluation of patients who are at higher risk of harm from opioid medications.7,8 Research conducted by Zedler et al has revealed some of the strong predictors of opioid induced respiratory depression and resulted in a novel risk index tool; Risk Index for Serious Prescription Opioid-Induced Respiratory Depression (RIOSORD).9 The risks of concurrent benzodiazepine use and high morphine milliequivalent doses are a few of the important factors when assessing a patient’s risk. The U.S. Surgeon General’s Advisory on Naloxone and Opioid Overdose reinforces or elaborates many of the criteria presented in the RIOSORD paper like concomitant benzodiazepine use and morphine equivalent doses above 50 MME/day.8,9
In addition, the therapy plan for many hospice patients emphasizes symptom management and often includes the use of benzodiazepines and opioid medications for the management of pain and anxiety.1 Management of these complex patients is often conducted by palliative care specialists and teams. The specialists are frequently deferred to for continued evaluation and treatment of patients because individualized care is particularly important for hospice patients, often who receive highly concentrated, high dose opioids, administered by family members or lay persons unfamiliar with such dosing or medications.7 The American Academy of Hospice and Palliative Medicine (AAHPM) released a public policy statement that promotes the appropriate and timely availability of prescription medications, with the recognition of the current public health imperative to provide collaborative care to promote the safety of the individual and public.10 It would seem that naloxone, a drug that exists for the purpose of safety, would fall into this category.
To oppose the use of naloxone or its provision in certain settings would equate to potentially hastening death in patients who are prescribed opioid medications. One concern often raised by those who oppose naloxone provision to hospice patients is the potential for a pain crisis if naloxone is administered. Although this is certainly possible it is important to remember that a critical step in naloxone administration is to contact emergency services.4,7 This is a genuine concern, but it should be viewed from the position of preventing an accidental opioid-induced death instead.
Following an evaluation by the palliative care specialists, a plan should be discussed with the patient and their family that includes education and potentially a prescription for naloxone for emergency use. A duty is owed to patients and their families to provide information necessary to make informed decisions. The option to have naloxone, especially when the risks of overdose are present, is critically important in fulfilling the goal of neither hastening nor postponing death. Hospice patients have a right to receive ethical, responsible (safe), and quality care.
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Guest Post by:
Dr. Persico graduated from Union Graduate College with an MBA in healthcare management in 2016 and completed her doctor of pharmacy at Albany College of Pharmacy and Health Sciences in 2017. She is currently a PGY2 Pain and Palliative Care Pharmacy Resident at the Stratton VA Medical Center in Albany, New York.
Nicholas C. Houle is a PharmD candidate in the class of 2020 at Western New England University in Springfield, MA. He is currently completing a series of rotations at the Stratton VA Medical Center. Following graduation, he plans to pursue a PGY1 residency with a focus in ambulatory care, and an interest in behavioral health.
Erica L. Wegrzyn, PharmD, is a clinical pharmacy specialist in pain management at the Stratton VA center, as well as a member of the adjunct faculty at Western New England University College of Pharmacy and the Albany College of Pharmacy & Health Sciences. Dr. Wegrzyn has authored numerous publications related to pharmacotherapeutics and pain and is an associate editor-in-chief for the Journal of Pain Research.
REFERENCES:
- Sera L, McPherson ML, Holmes HM. Commonly Prescribed Medications in a Population of Hospice Patients. Am J Hosp Care. 2014 Mar; 31(2): 126-131. Doi:10.1177/1049909113476132.
- TITLE XVIII – HEALTH INSURANCE FOR THE AGED AND DISABLED 1861. [42 U.S.C. 1395x] [Internet]. [cited 2019 Sep 9]. Available from: https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
- WHO Definition of Palliative Care [Internet]. [cited 2019 Sep 9]. Available from: https://www.who.int/cancer/palliative/definition/en/
- Narcan [package insert]. Radnor, PA: Adapt Pharma; 2017.
- Fudin J, Persico AL, Bettinger JJ, et al. The state of naloxone: Access amid a public health crisis.
- Barnett V, Twycross R, Mihalyo M, et al. Therapeutic Reviews: Opioid Antagonists. J Pain Symptom Manage. 2014 Feb; 47(2): 341-352.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
- S. Surgeon General’s Office. U.S. Surgeon General’s Advisory on Naloxone and Opioid Overdose [Internet]. 2018 [cited 2019 Sep 9]. Available from: https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html
- Zedler B, Xie L, Wang L et al. Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans’ Health Administration Patients. Pain Medicine. Jun 2015. 16;1566-1579
- Public Policy Priorities [Internet]. American Academy of Hospice and Palliative Medicine; 2019 [cited 2019 Sep 9]. Available from: http://aahpm.org/uploads/AAHPM_Public_Policy_Priorities_-_2019.pdf.
Standards of Practice for Hospice Programs: Professional Development and Resource Series [Internet]. Alexandria, VA: National Hospice and Palliative Care Organization; 2018 [cited 2019 Sep 9]. Available from: https://www.nhpco.org/wp-content/uploads/2019/04/Standards_Hospice_2018.pdf.
Thank you for your comment. Respectfully, patients who have chosen a natural death by making their DNR/DNI wishes known have not chosen to die via opioid overdose. In fact, to allow these patients to die from opioid overdose could be considered akin to “physical assisted death” and is most certainly not aligned with their wishes for a natural death.
To clarify- administration of naloxone will only serve to reverse the action of opioids via displacement from opioid receptors. Administration of naloxone will not make any other changes to the natural dying process if erroneously administered by a well intentioned family member. There is, in fact, no hazard in administering naloxone to someone who is not experiencing opioid overdose.
In short, naloxone in the hospice setting can allow the patient to fulfill their wishes of dying naturally rather than via opioid overdose. As stated in the above blog- failure to provide naloxone to patients in the hospice/palliative care setting could serve to hasten death rather than allow the natural dying process to take its course.
Amelia, I guess we can agree to disagree. Have you ever witnessed a patient given naloxone inappropriately and witnessed the dramatic and tragic consequences that this intervention causes? Is this what palliative care and hospice are about? Is this the outcome that one should expect from enrolling in a program that allows natural death? I also couldn’t disagree with you more with your statement “There is, in fact, no hazard in administering naloxone to someone who is not experiencing opioid overdose” this is 100% false. Finally, not everyone who takes opioids overdoses, and not everyone in hospice takes opioids. Therefore, the intervention of having naloxone available for this population in my opinion is unnecessary. Controversial topic, and good point, counterpoint, discussion.
I have to disagree with the position that we “should” recommend naloxone for patient’s who have chosen to have a natural death (DNR/DNI and hospice). I fear that well intentioned family/caregivers will inappropriately administer naloxone fearing overdose, but instead, is part of the natural dying process (for many something they have never experienced before).
My vote is to leave it to the professionals (first responders, EMT, police), and not in the hands of an untrained observer or caregiver. In the hospice setting I believe 1) It is unnecessary 2) Potentially harmful 3) Inconsistent with patient’s goals of care – natural death 4) Cannot be self administered
If you do have some naloxone nasal spray around the house, it might not be completely useless, as it could be used to treat opioid induced constipation (given orally).