With fentanyl leading to increased overdose deaths across Colorado, Naloxone and other drugs designed to reverse such overdoses are becoming essential to have on hand, said Dr. Don Stader, an addiction specialist and emergency physician at Swedish Medical Center. Naloxone should be available to people with substance use disorders just as epinephrine is available to people with allergies.
“If the only place you can get epinephrine is in the hospital, then we're going to lose a lot of people to allergic reactions,” Stader said. “It’s the same thing with opioids.”
The key difference, though, is that people who have allergies aren’t stigmatized, while those who have substance use disorders are, Stader said.
“When we give them a prescription for epinephrine, the chance that they go fill that prescription is extremely, extremely high,” Stader said. “When you talk about Naloxone … People receive stigma when they go to the pharmacy or feel ashamed that they're going and outing themselves as a substance user. People do not fill those prescriptions.”
Stader said there’s growing evidence that giving away Naloxone is the best way to get it into the hands of those at risk of overdose, but many hospitals were only doing this because of grants. Some even absorbed the costs themselves, which Stader said is how Swedish started as well.
Then came the Colorado Naloxone Project, which Stader started with the goal of having free, take-home Naloxone kits available in every hospital and emergency room thanks to funding from the Sandgaard Foundation and other partners. The goal is to get the overdose antidote into the hands of those most at risk of overdosing from an opiod like fentanyl or heroin. The kits include a Naloxone spray administered through the nostrils, rehab information as well as instructions on how to administer the antidote.
“The best type of medicine arms people for anticipated adverse outcomes or adverse events, especially when they're life threatening. Naloxone for potential opiate overdose is just one of those examples,” Stader said.
As the project enters its second year, Stader wants it to have a greater focus on making Naloxone available in more labor and delivery departments. Why? Because overdose is frequently cited as a top killer of expecting mothers.
According to the Centers for Disease Control and Prevention, opioid use disoder among pregnant women has more than quadrupled from 1999 to 2014, and numbers are growing each year. A Colorado Department of Public Health report on maternal mortality released in 2020 found that overdose was the second most common cause of pregnant women deaths in Colorado between 2014 and 2016. Of the 94 deaths reviewed in the report, the Colorado Maternal Mortality Review Committee found that mental health or substance use contributed to six out of 10 pregnancy-related deaths.
It makes sense that overdose is a leading cause of death for pregnanat mothers, Stader said, because most pregnant women are young adults, and the leading killer of young adults is also overdose.
“As we've seen a spiraling opioid and substance use crisis, there's many more mothers who are using substances when they become pregnant,” Stader said.
Mari Gambotto is a perinatal nurse practitioner at Swedish who has worked in high-risk obstetrics for 26 years. She said the number of expectant mothers who come in with substance use disorders has increased since she started in the field.
Her department has about 100 doses of Naloxone to distribute thanks to the Naloxone Project. Gambotto said her department scans every patient for substance use disorder. Having free Naloxone to give to them opens a conversation they otherwise might not have had.
“We’re giving them a gift, a free service, and so it opens up the dialogue to the patient,” Gambotto said. “There’s more benefit than just the drug.”
Dr. Lisa Becker, who works on the high-risk obstetrics service at Presbyterian/St. Luke's Medical Center, said she most frequently works with mothers admitted into the hospital for pregnancy complications who have longer hospital stays than most. She’s also involved with the Colorado Perinatal Care Quality Collaborative’s work around substance use disorders.
While Becker said methamphetamine exposure is what she sees most in her practice in regard to substance use, she said with fentanyl becoming more and more commonly mixed with other substances, people who don’t think they’re even in contact with opioids are at a higher risk of overdose.
“I'm in the place where I offer Naloxone kits to anybody who has a positive tox screen, or anybody who knows someone who may be at risk, because the whole point is to keep people alive and try to get them to treatment,” Becker said.
Stader said because of the stigma around substance use — particularly for pregnant mothers — many will hesitate to bring it up to their doctors. But if nurses and doctors start the conversation by letting patients know they give away Naloxone, they’re more likely to open up and discuss the issue “as a part of normal medical care,” Stader said.
To Becker, getting Naloxone into the hands of pregnant women could lead to two lives being saved with one drug. The stigma around substance use frustrates Becker, because while some may have been exposed to opiates for the first time recreationally, others first exposure comes from the medical field following a surgery or accident.
“We're not here to judge. We are here to try to help with what is a medical issue,” Becker said. “... I think we're never going to make progress with this until we start remembering that these are people who have an illness.”
Colorado House Bill 1065, which passed in 2020, requires that hospitals be reimbused for providing opiod antagonists by carriers that cover it, which Stader said is a first-of-its-kind bill bringing take-home Naloxone into “typical medical processes.”
Pregnancy is also a “really unique time in a mother’s life” that Stader said might motivate them to work toward recovery, and discussing the availability of Naloxone could be a small first step in that direction. Becker agrees, calling pregnant women the “ideal population” to help work toward recovery.
“Pregnancy in general is a time when a lot of women are very motivated to try to be healthier for their babies,” Becker said. “... They're often very receptive to conversations about how to have a healthier life for themselves and their children.”
On top of this, Becker said studies have shown that women are frequently the ones most involved in the health care decisions for famliy members, meaning they could reach others at risk of overdose, too.
Gambotto said she’s never had a patient decline the opportunity to speak with a neonatologist about how their substance use can impact their unborn baby.
“A healthy mom is a healthy baby,” Gambotto said. “So if we can be non judgmental and recognize this is an issue right now… without being judgmental and offering them resources, they will seek out to change on their own, because they have to do that by themselves.”
Kim Kramer, who is a corporate educator for the NICU and perninatal residency programs across Centura, previously worked as an educator at St. Francis Hospital in Colorado Springs, which is where she first got involved with the Naloxone Project. As the hospital’s OB educator, Kramer helped roll out staff education on the program.
“We knew the biggest hurdle was going to be that second patient,” Kramer said. “As soon as you throw a baby into the mix, you make people so afraid to admit that they have a problem.”
When starting training, Kramer said she was concerned about getting obstetrics nurses comfortable talking to patients about substance use disorder without stigma or judgment. She said talking to patients about it in an understanding way is key, because most of the mothers care about their child and want help, yet they don’t actively seek it out.
“They care so much about the child and they're so worried about what they're doing — hurting the child — that they really do want to get better and they really do want help. But they're afraid to reach out when they're pregnant because they know social services will get involved.”
Nurses ask all patients about history of substance use disorder or any family ties, because Kramer said people are more willing to admit someone they know uses than they are themselves. This still opens up the conversation on distributing free Naloxone, and if the patient does end up taking some home with them, Kramer said they discuss it with a significant other or family member so multiple people in the household know how to use it.
Becker remembers speaking to one patient who had methamphetamine in her system. She said the patient was reluctant to talk about it, as the medical system hadn’t previously been gracious to her. But once the pair sat down to talk and Becker explained the intentions of the Naloxone project, the patient opened up and admitted she wanted to get better.
“She told me that she had a niece who had overdosed multiple times, and I just thought … ‘You are the perfect person to have these kits at home, because there are lots of people around you who are at risk as well,’” Becker said. “The whole idea is to get these into the hands of people who may be able to help others in the community as well.”
