Naloxone coprescribing appears uncommon in patients taking long-term opioids

Patients at increased risk for opioid overdose often do not receive a coprescription for naloxone despite recommendations, a recent study found.

Researchers performed a retrospective cross-sectional study of deidentified claims from U.S. retail pharmacies nationwide to look at naloxone coprescribing in the general population, as well as how it varies by individual and community. The study included new opioid treatment episodes that began in 2017-2018 and lasted longer than 90 days; patients could have more than one long-term opioid episode. The study's primary outcome was coprescribed naloxone, defined as a filled naloxone prescription at any time during the long-term opioid episode or in the seven days before it began. 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 were evaluated as predictor variables. Results were published Feb. 17 by the Journal of General Internal Medicine.

The study included 5,129,159 unique patients with 6,060,728 long-term opioid therapy episodes in 2017-2018. A total of 59.6% of episodes were among women, and 61.3% were among those older than age 55 years. Medicare was the most common payer for long-term opioid episodes (40.9%), followed by commercial insurance (27.2%), other insurance (14.9%), and Medicaid (13.4%), with fewer than 5% of episodes paid for with cash. Overall, 2.3% of long-term opioid therapy episodes included naloxone coprescribing. Prescriptions billed to Medicaid (adjusted odds ratio [OR], 1.87; 95% CI, 1.84 to 1.90) and Medicare (adjusted OR, 1.48; 95% CI, 1.46 to 1.51) were more likely to have naloxone coprescribing than those billed to commercial insurance. Coprescribing was less likely with cash payment (adjusted OR, 0.77; 95% CI, 0.74 to 0.80) and other types of insurance (adjusted OR, 0.81; 95% CI, 0.79 to 0.83). Naloxone coprescribing was also more likely with high-dose opioid episodes (adjusted OR, 3.19; 95% CI, 3.15 to 3.23), with concomitant benzodiazepines (adjusted OR, 1.12; 95% CI, 1.10 to 1.14), and in counties where fatal overdose rates were higher.

The authors noted that their study looked at only filled prescriptions and only two years of data. However, they concluded that while coprescription of naloxone can help prevent deaths from opioid overdose and is recommended for patients at higher risk, rates in practice remain low. “Opportunities remain to expand co-prescribing of naloxone to patients receiving long-term opioid therapy,” they wrote. “Expanded education and use of academic detailing for prescribers and pharmacists on naloxone co-prescription, electronic health record alerts to prompt clinicians on naloxone co-prescribing when risk factors are present, and payment policy changes to reduce cost barriers for patients are strategies that states, insurers, and health systems should consider to facilitate increased provision of naloxone.”