Introduction There is clear guidance that naloxone should not be used for patients approaching end of life and should be used at a lower dose and with great caution in those receiving long term therapeutic opioids. After being asked to review a terminally ill patient with a reduced level of consciousness who had received boluses of naloxone and was about to be started on a naloxone infusion, we decided to examine local prescribing practice and assess whether guidelines are being adhered to.
Methods Data regarding naloxone prescribing was obtained for two three-month periods; prior to and following the introduction of a prescribing order set which included guidance on the indications for naloxone use and appropriate doses. The notes of all patients who received naloxone in each time period were reviewed; and only patients prescribed long term opioids for pain were included in the audit. Data collected included age, sex, type and dose of opioid, equivalent doses of oral morphine per day, dose of naloxone administered, stated indication for use, respiratory rate, oxygen saturations and time to death where applicable.
Results Prior to the intervention 15 patients were identified. All of these received inappropriately high doses of naloxone. Following the intervention, the number of patients reduced by more than 50% (n=7), however all patients still received inappropriate doses. Worryingly there were no patients in either time period who had documented evidence of respiratory depression; most clinicians cited reduced level of consciousness as the reason for administering the drug.
Conclusion This intervention may have reduced the number of inappropriate prescriptions of naloxone in this subset of patients. However, more education is required to improve knowledge around the appropriate use of this potentially harmful drug. Future training sessions are planned to include staff from the emergency department and acute medicine.
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