Individual and Community Factors Associated with Naloxone Co-prescribing Among Long-term Opioid Patients: a Retrospective Analysis

ABSTRACT

Background

Naloxone co-prescribing to individuals at increased opioid overdose risk is a key component of opioid overdose prevention efforts.

Objective

Examine naloxone co-prescribing in the general population and assess how co-prescribing varies by individual and community characteristics.

Design

Retrospective cross-sectional study. We conducted a multivariable logistic regression of 2017–2018 de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia.

Patients

Individuals with opioid analgesic treatment episodes > 90 days

Main Measures

Outcome was co-prescribed naloxone. Predictor variables included insurance type, primary prescriber specialty, receipt of concomitant benzodiazepines, high-dose opioid episode, county urbanicity, fatal overdose rates, poverty rates, and primary care health professional shortage areas.

Key Results

Naloxone co-prescribing occurred in 2.3% of long-term opioid therapy episodes. Medicaid (aOR 1.87, 95%CI 1.84 to 1.90) and Medicare (aOR 1.48, 95%CI 1.46 to 1.51) episodes had higher odds of naloxone co-prescribing than commercial insurance episodes, while cash pay (aOR 0.77, 95%CI 0.74 to 0.80) and other insurance episodes (aOR 0.81, 95%CI 0.79 to 0.83) had lower odds. Odds of naloxone co-prescribing were higher among high-dose opioid episodes (aOR 3.19, 95%CI 3.15 to 3.23), when concomitant benzodiazepines were prescribed (aOR 1.12, 95%CI 1.10 to 1.14), and in counties with higher fatal overdose rates.

Conclusion

Co-prescription of naloxone represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, we found that co-prescribing rates remain low overall. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.

This is a preview of subscription content, access via your institution.

REFERENCES

  1. 1.

    Wilson N, Kariisa M, Seth P, Smith HT, Davis NL. Drug and opioid-involved overdose deaths - United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2020;69(11):290-297.

    Article  Google Scholar 

  2. 2.

    Rose AJ, Bernson D, Chui KKH, et al. Potentially inappropriate opioid prescribing, overdose, and mortality in Massachusetts, 2011-2015. J Gen Intern Med. 2018;33(9):1512-1519.

    Article  Google Scholar 

  3. 3.

    Barnett ML, Olenski AR, Jena AB. Opioid-prescribing patterns of emergency physicians and risk of long-term use. N Engl J Med. 2017;376(7):663-673.

    Article  Google Scholar 

  4. 4.

    Coyle DT, Pratt CY, Ocran-Appiah J, Secora A, Kornegay C, Staffa J. Opioid analgesic dose and the risk of misuse, overdose, and death: A narrative review. Pharmacoepidemiol Drug Saf. 2018;27(5):464-472.

    Article  Google Scholar 

  5. 5.

    Public Policy Statement on the Use of Naloxone for the Prevention of Opioid Overdose Deaths. Chevy Chase, MD: American Society of Addiction Medicine; Undated: https://www.asam.org/docs/default-source/public-policy-statements/use-of-naloxone-for-the-prevention-of-opioid-overdose-deaths-final.pdf. Accessed May 15, 2020.

  6. 6.

    U.S. Health and Human Services. Naloxone: The Opioid Reversal Drug that Saves Lives. https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf. Published undated. Accessed May 11, 2020.

  7. 7.

    Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain--United States, 2016. JAMA. 2016;315(15):1624-1645.

    CAS  Article  Google Scholar 

  8. 8.

    Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155.

    CAS  Article  Google Scholar 

  9. 9.

    Abouk R, Pacula RL, Powell D. Association between state laws facilitating pharmacy distribution of naloxone and risk of fatal overdose. JAMA Intern Med. 2019.

  10. 10.

    Jones CM, Compton W, Vythilingam M, Giroir B. Naloxone co-prescribing to patients receiving prescription opioids in the Medicare Part D Program, United States, 2016-2017. JAMA. 2019;322(5):462-464.

    Article  Google Scholar 

  11. 11.

    Roberts AW. Naloxone prescribing among frequent opioid prescribers in Medicare Part D from 2013 to 2017: A retrospective study. J Gen Intern Med. 2020.

  12. 12.

    Frank RG, Fry CE. The impact of expanded Medicaid eligibility on access to naloxone. Addiction. 2019;114(9):1567-1574.

    Article  Google Scholar 

  13. 13.

    Guy GP, Jr., Haegerich TM, Evans ME, Losby JL, Young R, Jones CM. Vital Signs: Pharmacy-based naloxone dispensing - United States, 2012-2018. MMWR Morb Mortal Wkly Rep. 2019;68(31):679-686.

    Article  Google Scholar 

  14. 14.

    Sohn M, Talbert JC, Huang Z, Lofwall MR, Freeman PR. Association of naloxone coprescription laws with naloxone prescription dispensing in the United States. JAMA Netw Open. 2019;2(6):e196215.

    Article  Google Scholar 

  15. 15.

    Smart R, Geiger CK, Jones CM, Stein BD. An observational study of retail pharmacy naloxone prescriptions: differences across provider specialties and patient populations. J Gen Intern Med. 2019.

  16. 16.

    IQVIA: Real World Data and Insights. https://www.iqvia.com/solutions/real-world-evidence/real-world-data-and-insights. Accessed July 13, 2020.

  17. 17.

    National Center for Health Statistics. 2013 NCHS Urban–Rural Classification Scheme for Counties; Vol 2. Atlanta, GA: Centers for Disease Control and Prevention; 2014.

    Google Scholar 

  18. 18.

    Centers for Disease Control Prevention. Drug Overdose Deaths. https://www.cdc.gov/drugoverdose/data/statedeaths.html. Published 2020. Accessed May 20, 2020.

  19. 19.

    U.S. Census Bureau. Selected housing characteristics, 2007-2011 American Community Survey 5-year estimates. 2011.

    Google Scholar 

  20. 20.

    U.S. Department of Health and Human Services Health Resources and Services Administration. Area Health Resources Files. 2006-2019.

  21. 21.

    Follman S, Arora VM, Lyttle C, Moore PQ, Pho MT. Naloxone prescriptions among commercially insured Individuals at hgh risk of opioid overdose. JAMA Netw Open. 2019;2(5):e193209.

    Article  Google Scholar 

  22. 22.

    Centers for Disease Control Prevention. Reported Law Enforcement Encounters Testing Positive for Fentanyl Increase Across US. https://www.cdc.gov/drugoverdose/data/fentanyl-le-reports.html. Published 2016. Accessed May 20, 2020.

  23. 23.

    Chatterjee A, Larochelle MR, Xuan Z, et al. Non-fatal opioid-related overdoses among adolescents in Massachusetts 2012-2014. Drug Alcohol Depend. 2019;194:28-31.

    Article  Google Scholar 

  24. 24.

    Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: A cohort study. Ann Intern Med. 2010;152(2):85-92.

    Article  Google Scholar 

  25. 25.

    Green TC, Davis C, Xuan Z, Walley AY, Bratberg J. Laws mandating coprescription of naloxone and their impact on naloxone prescription in five US states, 2014-2018. Am J Public Health. 2020;110(6):881-887.

    Article  Google Scholar 

  26. 26.

    Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to laypersons - United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23):631-635.

    PubMed  PubMed Central  Google Scholar 

  27. 27.

    Thakur T, Frey M, Chewning B. Pharmacist roles, training, and perceived barriers in naloxone dispensing: A systematic review. J Am Pharm Assoc (2003). 2020;60(1):178-194.

    Article  Google Scholar 

  28. 28.

    Martino JG, Smith SR, Rafie S, Rafie S, Marienfeld C. Physician and pharmacist: Attitudes, facilitators, and barriers to prescribing naloxone for home rescue. Am J Addict. 2020;29(1):65-72.

    Article  Google Scholar 

  29. 29.

    Bounthavong M, Suh K, Christopher MLD, Veenstra DL, Basu A, Devine EB. Providers' perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment. Res Social Adm Pharm. 2020;16(8):1033-1040.

    Article  Google Scholar 

  30. 30.

    Unick GJ, Ciccarone D. US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations. Int J Drug Policy. 2017;46:112-119.

    Article  Google Scholar 

  31. 31.

    Rose AJ, McBain R, Schuler MS, et al. Effect of age on opioid prescribing, overdose, and mortality in Massachusetts, 2011 to 2015. J Am Geriatr Soc. 2019;67(1):128-132.

    Article  Google Scholar 

  32. 32.

    Xu J, Davis CS, Cruz M, Lurie P. State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies. Drug Alcohol Depend. 2018;189:37-41.

    Article  Google Scholar 

  33. 33.

    Behar E, Rowe C, Santos GM, Santos N, Coffin PO. Academic detailing pilot for naloxone prescribing among primary care providers in San Francisco. Fam Med. 2017;49(2):122-126.

    PubMed  Google Scholar 

  34. 34.

    Marino R, Landau A, Lynch M, Callaway C, Suffoletto B. Do electronic health record prompts increase take-home naloxone administration for emergency department patients after an opioid overdose? Addiction. 2019;114(9):1575-1581.

    Article  Google Scholar 

  35. 35.

    Bounthavong M, Harvey MA, Wells DL, et al. Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis. J Am Pharm Assoc (2003). 2017;57(2S):S68-S72.

    Article  Google Scholar 

  36. 36.

    Furlan A, Zhao J, Voth J. Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practicing in underserved areas. J Telemed Telecare. 2018;24:1357633X18782090.

    Google Scholar 

Download references

Acknowledgments

The authors would like to thank Mary Vaiana and Hilary Peterson for feedback on prior versions of this manuscript.

Funding

This work was supported by the National Institute on Drug Abuse (NIDA) through R21 DA045950 (Smart, PI), R01 DA045055 (Stein, PI), and P50 DA046351 (Stein, PI) and the National Center for Injury and Prevention Control (NCIPC) R01 CE002999 (Powell, PI).

Author information

Affiliations

Authors

Corresponding author

Correspondence to Bradley D. Stein MD, PhD.

Ethics declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Prior Presentations

None

Declarations

ESM 1

(DOCX 20 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Stein, B.D., Smart, R., Jones, C.M. et al. Individual and Community Factors Associated with Naloxone Co-prescribing Among Long-term Opioid Patients: a Retrospective Analysis. J GEN INTERN MED (2021). https://doi.org/10.1007/s11606-020-06577-5

Download citation

KEY WORDS

  • opioids
  • naloxone
  • overdose prevention
  • prescribing