Tox and Hound – Talking Back to a Talking Antidote

By Andrew Stolbach

Author’s note:

I sat down to discuss the role of the out-of-hospital naloxone administration with Evzio^® (Kaleo Pharmaceuticals), the world’s only talking naloxone auto-injector. Our interview is presented below in its entirety.

AS:

Thanks for coming today.

Evzio^®:

To Inject. Place black end against outer thigh. Then press firmly. 5, 4, 3, 2, . . . Injection complete.

AS:

That must be the thing you say when you are used for intramuscular naloxone injection. Thanks for that demonstration.

Evzio^®:

AS:

Alrighty then.

As you know, naloxone wasn’t always available to lay people. Until recently, naloxone had to be prescribed by a physician and dispensed by a pharmacist, like any other prescription medication. Now, naloxone prescription isn’t just common, it is endorsed by groups like the American College of Emergency Physicians (ACEP). Although all 50 states allow naloxone prescription to at-risk people, naloxone access laws have made it easier to for third-party prescriptions and non-patient-specific-prescriptions. Stop me if you know these terms already.

Evzio^®:

AS:

Then I’ll keep going.

Simply put, a third-party prescription is written for a person with the intent to be used on someone else, such as friends or family members. Many states permit this. Although most states have legal protections¹ for people carrying naloxone, it is not a crime for laypeople to carry or administer naloxone in accordance with state law. Most states also give immunity to drug possession charge when a person seeks or receives medical attention.

Evzio^®:

AS:

So, should I explain non-patient-specific-prescriptions?

Evzio^®:

AS:

Well, then. A non-patient-specific-prescription allows naloxone distribution without any interaction with a prescriber. This is a great option for people who can’t or won’t see a doctor. Depending on the state, a prescriber can write standing orders for pharmacies to dispense naloxone to anyone. Standing orders may be used by laypeople to distribute naloxone to other community members. In some jurisdictions, the authorization to prescribe comes from a state board of health or pharmacy.

Evzio^®:

AS:

Name one reason why lifesaving naloxone shouldn’t be an option for at-risk people who might not show up at a pharmacy or doctor’s office?

Evzio^®:

AS:

Exactly! You can’t. There are risks to naloxone, but they the pale in comparison to the benefit of naloxone – restarting breathing in overdose patients. About half of patients who get naloxone in the field from emergency responders and lay people have no negative symptoms at all. Around 5 to 11% of patients vomit, and 3 to 5% become combative.

AS:

Tell me if you need a break. Tox and Hound Headquarters has a full kitchen, a masseuse, and a gym. &Howard is available 24/7 for any technical needs.

Evzio^®:

AS:

We can hit the sauna later and get a shvitz?

Evzio^®:

AS:

Ok. I guess we will keep going. I would be remiss if I didn’t bring up this tough topic.

I want to talk about how Kaleo increased the list price of Evzio^® auto-injectors (like you) from $575 to $4,100 over the past 5 years. By comparison, Adapt Pharma sells simple intranasal Narcan^® for about $70 a dose. A white paper from the ACEP Trauma and Injury Prevention section describes a prescription naloxone kit (with an atomizer for intranasal use, a face shield, instructional video, and reference guide) that can be assembled for $68.21.

In fairness, you can talk, which may be helpful for laypersons or police officers who aren’t used to giving IM injections.

Is there anything you can say about this 9-fold price increase during a public health emergency?

Evzio^®:

AS:

Evzio^®:

AS:

Wow. Thanks for taking this interview.

Evzio^®:

You’re welcome.²

Resources

Consider prescription naloxone for certain patients at risk of opioid overdose:

Risk Factors for Opioid Overdose

(Adapted from Samuels EA et al)

• Received emergency care for opioid overdose
• Suspected opioid use disorder
• Take > 100 morphine equivalents/day
• Receive an opioid for pain and:
  • Are prescribed methadone or buprenorphine
  • Have poorly-controlled respiratory disease or infection, including sleep apnea³
  • Renal, liver, or heart disease
  • Alcohol use disorder
  • Concurrent benzodiazepine or other sedative use
  • Suspected poorly-controlled depression
  • Recent incarceration and opioid use
  • Recent resumption of opioid use after abstinence

Almost every state has specific legal protections for people lawfully distributing, carrying, or administering naloxone.

There are prescription assistance programs offered by local governments and pharmaceutical companies to help with the cost of naloxone.

A summary of naloxone access laws from SAMHSA.

Learn more about the specific opioid prescribing laws in your jurisdiction.

Want to start community naloxone distribution at your ED? Check out this white paper.
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