Naloxone Prescribing Research Articles

An evaluation of the association between specific post-overdose care services in emergency departments and subsequent treatment engagement.

The objective of this study was to estimate the association between receipt of specific post-overdose care services in the emergency department (ED) and subsequent engagement in treatment for opioid use disorder (OUD) after discharge. This was a retrospective cohort study of Rhode Island residents treated at 1 of 4 EDs for opioid overdose who were not engaged in OUD treatment and were discharged home (May 2016-April 2021). Electronic health record data were used to identify ED services received, and state administrative data were used to define subsequent engagement in OUD treatment within 30 days. Multivariable conditional logistic regression was used to estimate the association between ED services received and subsequent treatment engagement. Overall, 1008 people not engaged in OUD treatment were treated at study EDs for opioid overdose and discharged home, of whom 146 (14%) subsequently engaged in OUD treatment within 30 days. Most patients were aged 25 to 44 years (59%) and non-Hispanic White (69%). Receipt of behavioral counseling in the ED (adjusted odds ratio [aOR]=1.79, 95% confidence interval [CI]=1.18-2.71) and initiation of buprenorphine treatment in/from the ED (aOR=5.86, 95% CI=2.70-12.71) were associated with treatment engagement. Receipt of a take-home naloxone kit or naloxone prescription and referral to treatment at discharge were not associated with treatment engagement. Overall, 49% of patients received behavioral counseling in the ED, and 3% initiated buprenorphine in/from the ED. Strategies for increasing provision of behavioral counseling and initiation of buprenorphine in the ED may be useful for improving subsequent engagement in OUD treatment after discharge.

Trends in naloxone prescribed at emergency department discharge: A national analysis (2012–2019)

BackgroundWhile having access to naloxone is recommended for patients at risk for opioid overdose, little is known about trends in national naloxone prescribing rates in emergency departments (EDs) both for co-prescription with opioids and for patients who presented with opioid abuse or overdose. This study aims to evaluate the change in naloxone prescribing and opioid/naloxone co-prescribing at discharge using national data. MethodsWe conducted an IRB exempt retrospective review of data collected by the National Hospital Ambulatory Medical Care Survey from 2012 to 2019. The primary outcome was trend in rate of naloxone prescribing at discharge from ED visits. We also computed the proportion of visits where naloxone was both administered in the ED and prescribed at discharge, where naloxone and opioids were co-prescribed at discharge, and where an opioid was administered during the ED visit and naloxone was prescribed at discharge. All data were summarized using descriptive statistics and Spearman's Rho (SR) or Pearson's correlation (PR) were used to describe trends. ResultsThere was an estimated total of 250,365 patient visits where naloxone was prescribed at discharge with an increasing rate over time (0% of all ED visits in 2012 to 0.075% in 2019, p = 0.002). There were also increases in naloxone being both administered in the ED and prescribed at discharge (PC: 0.8, p = 0.02) as well as in naloxone and opioid co-prescribing (SR: 0.76, P = 0.03). There was an increase in utilization of opioids during the ED visit and naloxone prescribing at discharge for the same visit (SR: 0.80, p = 0.02). ConclusionThere are increases in naloxone prescribing at discharge, naloxone and opioid co-prescribing, and opioid utilization during the same visit where naloxone is prescribed at discharge. Future studies should be done to confirm such trends, and targeted interventions should be put into place to increase access to this life-saving antidote.

Implementation of a bundle to improve HIV testing during hospitalization for people who inject drugs.

Increased HIV testing is essential to ending the HIV epidemic. People who inject drugs (PWID) are among the highest risk for HIV infection. Previous research at Tufts Medical Center identified low HIV testing rates in hospitalized PWID. Our research team aimed to identify and overcome barriers to inpatient HIV screening of PWID using implementation science methods. Stakeholders were engaged to gather perspectives on barriers and facilitators of HIV testing. A PWID care bundle was developed and implemented, which included (1) HIV screening; (2) hepatitis A, B, and C testing and vaccination; (3) medications for opioid use disorder; and (4) naloxone prescription. Strategies from all nine Expert Recommendations for Implementing Change (ERIC) clusters guided the implementation plan. Stakeholder feedback was gathered throughout implementation, and implementation outcomes of acceptability and feasibility were assessed. PWID overall felt comfortable with HIV testing being offered while hospitalized. Clinicians cited that the main barriers to HIV testing were discomfort and confusion around consenting requirements. Many resident physicians surveyed reported that, at times, they forgot HIV testing for PWID. Overall, though, resident physicians felt that the PWID bundle was useful and did not distract from other patient care responsibilities. Engagement of key stakeholders to increase HIV testing in an inpatient setting led to the implementation of a PWID bundle, which was feasible and acceptable. Bundling evidence-informed care elements for inpatient PWID should be investigated further.

Characteristics and health service use of Medicaid-insured individuals filling naloxone under a standing order in Louisiana

BackgroundNaloxone distribution is a key intervention to reduce opioid overdose deaths. On January 23, 2017, Louisiana implemented a standing order that permits pharmacies to dispense naloxone to patients without a patient-specific prescription. ObjectivesTo examine the characteristics and health service use of Louisiana Medicaid members filling naloxone under the standing order. MethodsWe conducted a retrospective cohort study of Louisiana Medicaid members from January 23, 2017 to December 31, 2019. We extracted fee-for-service claims and managed care encounters for naloxone dispensed under the standing order. ResultsOverall, there were 2053 naloxone fills by 1912 unique individuals. The total number of naloxone fills increased from 22 in 2017 to 1218 in 2019. Most members (n = 1,586, 83.0%) received any type of health service and 20.4% (n = 391) received an opioid-related health service in the 30 days prior to filling naloxone. Additionally, 12.7% (n = 242) of members had received medication for opioid use disorder (MOUD), and 42.6% (n = 815) filled a prescription opioid analgesic within the 60 days prior to filling naloxone. Nineteen members (1.0%) had an emergency department visit for overdose within 90 days after filling naloxone. ConclusionStanding orders play an important role in providing access to naloxone, even among Medicaid members who had recent encounters with health care providers. We identified multiple opportunities to improve naloxone prescribing among providers caring for Medicaid-insured people who use opioids, including prescribers of opioid analgesics or MOUD.

Predictive Factors Associated with Naloxone Prescription among Pregnant People Admitted for the Management of Opioid Use Disorder.

Our objective was to examine the biomedical and sociodemographic factors associated with the prescription of naloxone among pregnant people with opioid-use disorder (OUD) who were admitted for initiation of medications for OUD (i.e., buprenorphine-containing medications or methadone) following the implementation of a statewide initiative focused on reducing adverse perinatal health outcomes. This is a single-site, retrospective cohort study of pregnant people admitted for the management of OUD at an urban, tertiary care center between 2013 and 2020. The primary outcome is evidence of a prescription of naloxone, ascertained from the electronic medical record. Bivariate and multivariable logistic regression modeling was performed to evaluate biomedical and sociodemographic variables associated with a prescription for naloxone. Covariates for inclusion in the multivariate logistic regression model were selected based on a p < 0.05 on bivariate analysis. Statistical significance was set at p < 0.05. One hundred and thirty-nine participants met the inclusion criteria. On bivariate analysis, people who received naloxone were more likely to be admitted after the initiation of a statewide initiative focused on reducing adverse perinatal outcomes associated with perinatal OUD. Those individuals reporting intravenous drug use (IVDU) were less likely to receive naloxone. On multivariate logistic regression, after controlling for IVDU and epoch of admission, both IVDU (adjusted odds ratio [aOR]: 0.27, 95% confidence interval [CI]: 0.11-0.70) and epoch of admission (aOR: 3.48, 95% CI: 1.28-9.50) were independently associated with receipt of prescription of take-home naloxone. Naloxone prescription was independently associated with the epoch of admission and route of drug administration. These data can be useful in the evaluation and development of clinical practices to increase rates of naloxone prescription in pregnant people with OUD admitted for inpatient management. · Thirty four percent of individuals with perinatal OUD were prescribed take-home naloxone (THN).. · Epoch of admission and route of drug administration were independently associated with THN.. · These data can be used to guide public health and clinical programming for pregnant people..

Collaborative approach to harm reduction by managed care pharmacy team for populations with substance use disorder

BackgroundOregon has one of the highest rates of substance use and substance use disorders (SUDs) in the nation. To improve access to SUD treatment in Oregon, CareOregon clinical pharmacists in collaboration with the behavioral health team have implemented these best practices to support members with SUD. ObjectiveThe primary objective of this article is to describe the various harm reduction programs and interventions implemented by managed care clinical pharmacists at CareOregon to prevent overdose and ensure improved health outcomes for populations with SUD. Practice descriptionThe CareOregon team of managed care clinical pharmacists acts as a liaison with provider networks by providing pharmacy benefit knowledge and implementing several interventions and best practices to improve health outcomes for populations with SUD. Practice innovationThe managed care clinical pharmacist team implemented a medication education (MEDS Ed) program to provide educational support to the CareOregon provider network on harm reduction, supported medication for opioid use disorder (MOUD) program initiatives to increase buprenorphine prescribing, and used programs to increase naloxone access for populations at high risk of overdose. Evaluation methodsA mixed-method approach was applied to evaluate the impact of the practice innovations implemented. A qualitative self-assessment questionnaire was used to evaluate the impact of the harm reduction MEDS Ed. Quantitative data accessed via CareOregon’s claims data were used to evaluate the effect of initiatives to expand naloxone access and increase buprenorphine prescribing. ResultsThe CareOregon provider network reported an increase in knowledge about harm reduction by attending the MEDS Ed training. From the first quarter of 2019 to the second quarter of 2022, the number of naloxone prescriptions filled increased by 346%. From the third quarter of 2017 to the first quarter of 2022, the number of Drug Addiction Treatment Act–waivered providers prescribing buprenorphine increased by 331%. As a result, the number of prescriptions for MOUD doubled during this period. ConclusionThe harm reduction interventions implemented by the managed care clinical pharmacist team at CareOregon were successful in improving knowledge on harm reduction and increasing naloxone access and buprenorphine prescribing for populations at risk of opioid use disorder.

Design of a pragmatic clinical trial to improve screening and treatment for opioid use disorder in primary care

BackgroundOpioid-related deaths continue to rise in the U.S. A shared decision-making (SDM) system to help primary care clinicians (PCCs) identify and treat patients with opioid use disorder (OUD) could help address this crisis. MethodsIn this cluster-randomized trial, primary care clinics in three healthcare systems were randomized to receive or not receive access to an OUD-SDM system. The OUD-SDM system alerts PCCs and patients to elevated risk of OUD and supports OUD screening and treatment. It includes guidance on OUD screening and diagnosis, treatment selection, starting and maintaining patients on buprenorphine for waivered clinicians, and screening for common comorbid conditions. The primary study outcome is, of patients at high risk for OUD, the percentage receiving an OUD diagnosis within 30 days of index visit. Additional outcomes are, of patients at high risk for or with a diagnosis of OUD, (a) the percentage receiving a naloxone prescription, or (b) the percentage receiving a medication for OUD (MOUD) prescription or referral to specialty care within 30 days of an index visit, and (c) total days covered by a MOUD prescription within 90 days of an index visit. ResultsThe intervention started in April 2021 and continues through December 2023. PCCs and patients in 90 clinics are included; study results are expected in 2024. ConclusionThis protocol paper describes the design of a multi-site trial to help PCCs recognize and treat OUD. If effective, this OUD-SDM intervention could improve screening of at-risk patients and rates of OUD treatment for people with OUD.

Electronic Advisories Increase Naloxone Prescribing Across Health Care Settings.

Naloxone is a life-saving, yet underprescribed, medication that is recommended to be provided to patients at high risk of opioid overdose. We set out to evaluate the changes in prescriber practices due to the use of an electronic health record (EHR) advisory that prompted opioid prescribers to co-prescribe naloxone when prescribing a high-dose opioid. It also provided prescribers with guidance on decreasing opioid doses for safety. This was a retrospective chart abstraction study looking at all opioid prescriptions and all naloxone prescriptions written as emergency department (ED) discharge, inpatient hospital discharge, or outpatient medications, between July 1, 2018, and February 1, 2020. The EHR advisory went live on June 1, 2019. Included in the analysis were all adult patients seen in the abovementioned settings at a large county hospital and associated outpatient clinics. We performed an interrupted time series analysis looking at naloxone prescriptions and daily opioid dosing in morphine milligram equivalents (MMEs), before and after initiation of the EHR advisory. The EHR advisory was associated with changes in prescribers' behavior, leading to increased naloxone prescriptions and decreased prescribed opioid doses. EHR advisories are an effective systems-level intervention to enhance the safety of prescribed opioids and increase rates of naloxone prescribing.

Medicaid expansion and access to naloxone in metropolitan and nonmetropolitan areas.

The opioid crisis remains a major public health concern in the United States. Naloxone is used to reverse opioid overdoses. This study examined Medicaid expansion on naloxone prescriptions in retail pharmacies in metropolitan (metro) and nonmetropolitan (nonmetro) areas (2011-2017). We used population average models to evaluate the association of Medicaid expansion at the state level on the number of naloxone prescriptions dispensed and the percentage paid by Medicaid, including adjustment for opioid-related and state-level policy covariates. Difference-in-difference modeling was performed as a sensitivity analysis. States that expanded Medicaid had higher unadjusted naloxone dispensing rates and Medicaid-paid percentage of naloxone in metro and nonmetro areas. Medicaid expansion was not associated with the number of naloxone dispensed in either metro (adjusted rate ratio (ARR) = 1.26, 95% CI: [0.80, 1.97]) or nonmetro (ARR = 0.67, 95% CI: [0.37, 1.19]) areas after covariate adjustment. In metro areas, Medicaid expansion was associated with a significant increase of 3.86 percentage points (95% CI: [0.09, 7.63]) in the Medicaid-paid percentage of naloxone dispensing compared to nonexpansion states, but this association was not significant in nonmetro areas. There was also a significant time by Medicaid expansion interaction on the Medicaid-paid percentage of naloxone dispensed (metro: estimate = 0.74, 95% CI: [0.36, 1.12]; nonmetro: estimate = 0.68, 95% CI: [0.17, 1.18]). Medicaid expansion increased naloxone access by increasing the Medicaid-paid percentage of naloxone prescriptions in metro areas. States with Medicaid expansion had a faster rate of increase in the Medicaid-paid percentage of naloxone than states without Medicaid expansion in nonmetro areas.

Readiness of community pharmacies to implement an opioid safety intervention

BackgroundWe report on efforts to measure readiness to adopt opioid safety initiatives in community pharmacies within 2 large chains. Previous studies identified lack of knowledge, confidence, or enthusiasm in addressing harm reduction efforts. We implemented an intervention that provided training to improve opioid safety. The goal was to increase naloxone prescribing and nonprescription syringe sales, reduce stigma, and decrease opioid overdoses among patients and customers. ObjectivesTo assess pharmacy readiness for intervention delivery, by characterizing pharmacy culture around opioid safety; describing current practices and challenges interacting with patients and customers on naloxone, nonprescription syringe sales, and buprenorphine; and determining pharmacy defined goals for implementing the intervention. MethodsThe sample included pharmacy managers and staff pharmacists from 2 large chains who completed a brief phone interview. Interviews consisted of Likert-scale and open-ended, theoretically driven questions. Questions focused on workplace culture, patient engagement, naloxone and buprenorphine prescribing, nonprescription syringe sales, and intervention goals. Coding categories for the open-ended questions were derived using a thematic review of responses. ResultsA total of 163 respondents described both workplace culture and how they encourage patient opioid safety as including public health awareness, patient engagement, and naloxone prescribing. Sale of nonprescription syringes exhibited high variability: no sales barriers (53.9%), sales with barriers (21.5%), and no sales (20.9%). Half of pharmacists (50.3%) interacted with buprenorphine prescribers outside of medication fills. Most respondents (68.7%) endorsed being ready to promote the intervention. Pharmacists named goals in adopting the intervention of wanting more knowledge and educational materials, talking points with patients, and best practices for offering naloxone. ConclusionCommunity pharmacists, before implementation, described awareness of and receptiveness to opioid safety initiatives, with substantial barriers around nonprescription syringe sales. Assessed knowledge level, culture, and identified barriers that emerged in the readiness assessments can be used to tailor future pharmacy-specific programming.

Implementation of a Naloxone Best Practice Advisory Into an Electronic Health Record.

Naloxone is a harm reduction tool for mitigating the rising rate of opioid overdose deaths. We sought to develop and implement an alert in the electronic health record outlining which patients are at higher risk of opioid overdose and should be coprescribed naloxone. Our aim was to increase coprescribing of naloxone to qualified patients. We also endeavored to evaluate naloxone prescription volume, fill rates, and statewide dispenses before and after alert implementation. We developed the electronic alert according to a state opioid safety initiative specifying under which conditions it should activate. We collected data on naloxone prescriptions ordered in the 5 months before and after alert implementation and unique patients with a naloxone dispense statewide. We used internal pharmacy data to evaluate the percentage of fills and used a χ 2 test to assess changes in percentage of fills. We used descriptive statistics and t tests to analyze changes in the number of prescriptions and changes in unique patients dispensed naloxone. We found a 2144% increase in the number of monthly naloxone prescriptions written after the alert became active. There was no statistically significant change in the percentage of fills. There was a 402.8% increase in unique patients statewide with a naloxone dispense after alert implementation. Designing and implementing an electronic alert prompting naloxone coprescription are feasible and were associated with substantial increases in numbers of naloxone prescriptions and patients with naloxone dispenses statewide. Our findings expand on prior literature about electronic decision support for naloxone coprescription.

Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System.

The aim was to determine the association between the receipt of naloxone and emergency department (ED) visits within 60 days after the receipt of an opioid. A retrospective cohort of individuals 18 years of age or above, enrolled in TRICARE, and were dispensed an opioid at any time from January 1, 2019, through September 30, 2020 was identified within the United States Military Health System. Individuals receiving naloxone within 5 days of the opioid dispensing date were propensity score matched with individuals receiving opioids only. A logistic regression was used to estimate the odds of an ED visit in the 60-day follow-up period after the index opioid dispense event among those co-dispensed naloxone and those receiving opioids only. Of the 2,136,717 individuals who received an opioid prescription during the study period, 800,071 (10.1%) met study inclusion criteria. Overall, 5096 (0.24%) of individuals who received an opioid prescription were co-dispensed naloxone. Following propensity score matching, those who received naloxone had a significantly lower odds of ED utilization in the 60 days after receiving an opioid prescription (odds ratio: 0.74, 95% CI: 0.68-0.80, P&lt;0.001). This study highlights the importance of expanding access to naloxone in order to reduce ED utilization. Future research is needed to examine additional outcomes related to naloxone receipt and develop programs that make naloxone prescribing a routine practice.

Examining the effects of COVID-19 on pharmacy dispensing of naloxone and syringes sales across Massachusetts and New Hampshire

BackgroundCoronavirus disease 2019 (COVID-19) lockdowns disrupted access to harm reduction supplies and services known to be effective in overdose prevention and contributed to a worsening of the opioid crisis. However, because pharmacies can provide naloxone and sell over-the-counter (OTC) sterile syringes, their continued operation throughout the pandemic potentially reinforced a public health role as a distribution hub for safer use supplies. ObjectivesThe objective of this analysis was to examine patterns of naloxone and OTC syringe sale volume at 463 community pharmacies in 2 states with high overdose rates during the COVID-19 pandemic. MethodsWe analyzed weekly pharmacy-level dispensing data from January 5, 2020, to December 31, 2020, from one corporate community pharmacy chain in Massachusetts (n = 415 pharmacies) and New Hampshire (n = 48 pharmacies). Descriptive statistics and visualizations over the analytical period were generated as initial explorations of the outcome. Zero-inflated Poisson and negative binomial models were used to analyze distribution data along with county-level COVID-19 case rates and store-level COVID-19 testing location status during the same time. Interactions tested the effect of COVID-19 case rates on naloxone and OTC syringe sales. ResultsPharmacies that reported selling nonprescription syringes and dispensing naloxone during the study period averaged 210.13 OTC syringes sold and 0.53 naloxone prescriptions per week. Pharmacies in communities that experienced greater COVID-19 case burden also exhibited higher naloxone dispensing and OTC syringe sales during this period. The odds of selling OTC syringes increased over time but naloxone dispensing remained constant over the pandemic year. Pharmacies hosting COVID-19 testing tended to have lower OTC syringe sales and naloxone provision than nontesting sites. ConclusionDuring the COVID-19 pandemic, pharmacies provided harm reduction services and dispensed lifesaving medications by quickly adapting to fulfill community needs without disrupting co-located services for COVID-19 response.

The impact of a provider motivational interviewing-based training on chronic pain management in a federally-qualified health center.

While the issue of opioid misuse is very complex, pharmacists have a unique opportunity to participate in interprofessional, team-based care. Motivational interviewing (MI) has been shown to be effective in chronic disease management and could improve patient engagement and chronic pain outcomes. To determine the impact of an MI-based provider training on changes in chronic pain management prescribing and on provider and patient perceptions. Providers participated in a pharmacist-led, 4-session educational intervention covering the CDC opioid prescribing guidelines, pain management, clinical pearls, and MI. Providers were then asked to implement the training in patient appointments for chronic pain management and refer appropriate patients for follow-up on goals. In the follow-up, student pharmacists called patients twice monthly for three months using MI. To address the primary outcome, the number of opioid prescriptions, morphine daily equivalents, and naloxone prescriptions were recorded and compared from the electronic medical record for the year preceding and following the intervention. Patients and providers completed surveys to assess the impact of these interventions. Providers (n=11) reported increased confidence in MI from baseline to 12 months following the intervention but no change in satisfaction. Patients (n=19) were able to set and accomplish 20 goals throughout the phone call intervention. Meanwhile, the number of opioid prescriptions significantly decreased from 569 to 368 prescriptions per year before and after the intervention, respectively. Morphine daily equivalents per prescription decreased from 26.8 to 26.4 for the year before versus the year following the intervention. MI interventions for providers and patients may positively impact goal setting and opioid prescribing. However, MI alone may not successfully address provider satisfaction and patient physical functioning. Pain management is an area that may benefit from a multi-faceted, interprofessional approach.

35 Increasing Naloxone Prescriptions Through Electronic Medical Record Best Practice Advisory Alerts

Study Objectives: Overdoses are now the leading cause of injury-related death in the United States with recent increases influenced by multiple factors including the COVID-19 pandemic. Among the most recent overdose deaths, about 75% involved a prescription or illicit opioid. Naloxone can rapidly reverse fatal overdose and evidence shows reduced mortality when naloxone is available in the community. Although emergency physicians are generally willing to prescribe naloxone to patients at risk of opioid overdoses, prescriptions remain uncommon.

Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration

BackgroundEmergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription.MethodsWe conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences.ResultsOf the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge.ConclusionsNaloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

Trends in Out-of-Pocket Costs for Naloxone by Drug Brand and Payer in the US, 2010-2018

Improving access to naloxone is a critical component of the nation's strategy to curb fatal overdoses in the opioid crisis. Standing or protocol orders, prescriptive authority laws, and immunity provisions have been passed by states to expand access, but less attention has been given to potential financial barriers to naloxone access. To assess trends in out-of-pocket (OOP) costs for naloxone and examine variation in OOP costs by drug brand and payer. This observational study analyzed US naloxone claims data from Symphony Health and associated OOP costs for individuals filling naloxone prescriptions by drug brand and payer between January 1, 2010, to December 31, 2018. The data were analyzed from March 31, 2021, to April 12, 2022. The main measures were trends in annual number of naloxone claims (overall, by payer, and by drug brand) and mean annual OOP costs per claim (overall, by payer, and by drug brand). Of 719 612 naloxone claims (172 894 generic naloxone, 501 568 Narcan, and 45 150 Evzio) for 2010 through 2018, the number of naloxone claims among insured patients began rapidly increasing after 2014; at the same time, the mean OOP cost of naloxone increased dramatically among the uninsured population. Comparing 2014 with 2018, the mean OOP cost of naloxone decreased by 26% among those with insurance but increased by 506% among uninsured patients. For the uninsured population, the impediment of cost was even larger for certain brands of the drug. In 2016, the mean OOP cost for Evzio among uninsured patients rose to $2136.37 (a 2429% increase relative to 2015) compared with the mean cost of generic naloxone, $72.88, and the cost of Narcan in its first year, $87.95. Throughout the period, the mean OOP costs paid by uninsured patients were higher for Evzio at $1089.17 (95% CI, $884.17-$1294.17) compared with $73.62 (95% CI, $69.24-$78.00) for Narcan and $67.99 (95% CI, $61.42-$74.56) for generic naloxone. In this observational study, the findings indicated that the OOP cost of naloxone had been an increasingly substantial barrier to naloxone access for uninsured patients, potentially limiting use among this population, which constituted approximately 20% of adults with opioid use disorder.

Disparities in naloxone prescriptions in a University Hospital during the COVID-19 pandemic

BackgroundPer the CDC, it is estimated that 69,710 opioid overdose deaths occurred in the United States from September 2019 to September 2020. However, it is unclear whether naloxone prescribing also increased or otherwise fluctuated in this time. The objective of this study was to characterize the naloxone prescribing rate in patients with opioid use disorder (OUD) at the University of Alabama at Birmingham Hospital in 2019 and 2020.MethodsA cross-sectional, retrospective medical record review was performed on patients with OUD from January 2019 through December 2020. Naloxone prescribing, defined as either a written prescription or a provided take-home kit, was assessed for all patients with OUD.ResultsIn 2019, 11,959 visits were made by 2962 unique patients with OUD, compared to 11,661 visits from 2,641 unique patients in 2020; 609 naloxone prescriptions were provided in 2019 (5.1%) and 619 in 2020 (5.3%). In both years, most OUD-related visits and naloxone prescriptions were from and to male, white, individuals. Compared with 2019, more naloxone prescriptions were given to uninsured patients in 2020 (33.2% vs 44.3%, p < 0.05), and more OUD patients were admitted to inpatient settings (26.0% vs 31.2%, p < 0.05) and received more naloxone prescriptions in the inpatient setting (46.3% vs 62.0%, p < 0.05) in 2020. The proportion of frequent users (i.e., visits ≥ 4 times/year) increased in 2020 for the emergency department (21.5% vs 26.4%, p < 0.001) and inpatient setting (24.9% vs 28.6%, p = 0.03).ConclusionsOur findings indicate the need for improving naloxone awareness in providers and prescribing for patients with OUD, particularly in emergency department and outpatient settings. Our results also demonstrated a disparity in naloxone prescribing; a disproportionate number of opioid-related emergency department visits and overdose deaths were noted in Black people and frequent users.

The Rural Opioid Initiative Consortium description: providing evidence to Understand the Fourth Wave of the Opioid Crisis

ObjectiveTo characterize and address the opioid crisis disproportionately impacting rural U.S. regions.MethodsThe Rural Opioid Initiative (ROI) is a two-phase project to collect and harmonize quantitative and qualitative data and develop tailored interventions to address rural opioid use. The baseline quantitative survey data from people who use drugs (PWUD) characterizes the current opioid epidemic (2018–2020) in eight geographically diverse regions.ResultsAmong 3,084 PWUD, 92% reported ever injecting drugs, 86% reported using opioids (most often heroin) and 74% reported using methamphetamine to get high in the past 30 days; 53% experienced homelessness in the prior 6 months; and 49% had ever overdosed. Syringe service program use varied by region and 53% had ever received an overdose kit or naloxone prescription. Less than half (48%) ever received medication for opioid use disorder (MOUD).ConclusionsThe ROI combines data across eight rural regions to better understand drug use including drivers and potential interventions in rural areas with limited resources. Baseline ROI data demonstrate extensive overlap between opioid and methamphetamine use, high homelessness rates, inadequate access to MOUD, and other unmet needs among PWUD in the rural U.S. By combining data across studies, the ROI provides much greater statistical power to address research questions and better understand the syndemic ofinfectious diseases and drug use in rural settings including unmet treatmentneeds.

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation of a Quality Improvement Project in a Large Health System

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent prescriptions for opioids and benzodiazepines or sedative/hypnotics, a diagnosis of substance use disorder, or a history of opioid overdose. Our interventions included (1) a standing order for naloxone in the hospital pharmacy, (2) in-person naloxone trainings for all clinical and non-clinical primary care staff, (3) online training modules, (4) guidelines on naloxone co-prescribing sent via email, and (5) automated alerts in the electronic medical record (EMR). To evaluate these interventions, the EMR for, was queried for patients with one or more risk factors for opioid overdose, and whether they had naloxone on their medication list between 2017 and 2020. Results: Over the course of the study period, overall rate of naloxone co-prescribing system-wide increased from 0.4% to 26% of patients. Automatic EMR alerts were associated with an increase of 4.5%, the largest single-quarter increase. Online education modules and guideline dissemination were associated with smaller increases of 0.9% and 3% in the two quarters following their implementation. In-person trainings and making naloxone available without a prescription were followed by Conclusions: Our most effective intervention was automatic alerts in the EMR, while e online trainings and guidelines produced modest effects. A notable increase was also seen in one hospital system whose entire leadership and staff deliberately prioritized increasing naloxone access. Even with these gains, we have not yet achieved adequate co-prescribing across our system.