Criteria to Prescribe Naloxone
Prescribe take-home naloxone to patients receiving ≥50 morphine milligram equivalents (MME) daily, those co-prescribed benzodiazepines or other sedating agents (gabapentinoids), and anyone with a history of opioid use disorder or overdose. 1
Primary Prescribing Criteria
High-Risk Opioid Dosing
- ≥50 MME/day: Consider naloxone as a rescue resource, particularly if there is concern for unintended access by children or cognitively impaired family members 1
- ≥90 MME/day: Strong indication for naloxone coprescribing 2, 3
Concurrent Medications
- Benzodiazepine co-prescription: Prescribe naloxone regardless of opioid dose 1
- Gabapentinoids or other sedating agents: Prescribe naloxone when combined with opioids 1
Patient History
- History of opioid use disorder: Automatic indication for naloxone 4
- Previous opioid overdose: Automatic indication for naloxone 4
Additional At-Risk Populations
The following groups should receive naloxone education and prescriptions 4:
- Persons who abuse prescription opioids or heroin
- Patients recently released from incarceration (higher overdose risk)
- Patients recently discharged from emergency department after overdose treatment
- Patients with periods of opioid abstinence (reduced tolerance)
- Household members, family, or close contacts of individuals at risk
Formulation Selection
Both intranasal and intramuscular auto-injector formulations are FDA-approved for lay rescuer use 4. Selection should be based on:
- Intranasal naloxone: 4 mg dose, can repeat in 3-5 minutes if needed 4
- Intramuscular auto-injector: FDA-approved for both lay rescuers and healthcare providers 4
- Both routes have demonstrated successful use in first aid settings 4
Essential Patient Education Components
When prescribing naloxone, ensure patients and caregivers understand 1, 4:
- Recognition of overdose: Severe CNS depression, respiratory depression, unresponsiveness
- Administration technique: Route-specific instructions
- Short half-life: Naloxone duration (~45-70 minutes) may be shorter than opioid effects; repeat doses may be needed 5
- Call emergency services: Always activate emergency response even after naloxone administration
- Continued monitoring: Need for ongoing observation after initial response
Important Clinical Caveats
- End-of-life considerations: Ensure naloxone administration aligns with patient's goals of care 1
- Withdrawal risk: Naloxone may precipitate acute withdrawal in opioid-dependent patients (hypertension, tachycardia, agitation, vomiting), but these symptoms are rarely life-threatening 4
- Long-acting opioids: Patients on methadone or extended-release formulations require longer observation periods due to prolonged opioid effects 5
Prescribing Barriers to Overcome
The most commonly cited barriers are lack of time during visits and inadequate naloxone administration education 6. Pharmacist-led interventions and standing order sets can effectively address these barriers 6. Clinical decision support alerts in electronic health records have increased naloxone coprescribing rates from 0.28% to 4.51% of opioid prescriptions 7.