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



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


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


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.


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.


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.

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


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).

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Correspondence to Bradley D. Stein MD, PhD.

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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).

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  • opioids
  • naloxone
  • overdose prevention
  • prescribing