Low naloxone prescriptions among individuals at high risk of opioid-related overdose despite healthcare interactions

From the 2019 HVPAA National Conference

Ms. Sarah Follman (Pritzker School of Medicine), Dr. Vineet Arora (Pritzker School of Medicine), Mr. Christopher Lyttle (University of Chicago), Dr. P. Quincy Moore (University of Chicago), Dr. Mai Pho (University of Chicago)

Background

As opioid-related mortality continues to rise, naloxone remains a critical intervention in preventing overdose death. Expanding access should be optimized to promote equity. Engaging providers to regularly prescribe naloxone is important to advocate for this vulnerable population. The primary goal of our analysis was to determine the extent to which patients at high risk of opioid overdose receive naloxone.

Method

Using Truven Health MarketScan®, a national database of commercial insurance claims, we investigated naloxone prescriptions among high-risk patients accessing emergency, inpatient, and outpatient care. We identified patients between October 1, 2015 – December 31, 2016 and grouped them into three categories using ICD-10 codes: 1) patients with opioid misuse or dependence, 2) patients with opioid overdose, and 3) patients with both opioid misuse or dependence and overdose. We then linked patients in each group to their outpatient pharmacy claims. We compared naloxone pharmacy claims by opioid risk group using a Chi-Square test. Additional Chi-square tests characterized the groups across various demographic and healthcare utilization variables. We performed a multivariate logistic regression model to test the association between opioid risk group and naloxone claim, controlling for various demographic and healthcare utilization variables.

Results

Of the 138,108 individuals identified as high-risk opioid users, 2,135 had naloxone claims, or 1.5% of the eligible patients identified. Differences in naloxone claims across opioid risk group were statistically significant (p<0.001). Only 1.5% of those with a diagnosis of opioid misuse/dependence and 0.8% of those with an opioid overdose diagnosis received naloxone. Of those with both an opioid misuse/dependence diagnosis and an opioid overdose diagnosis, only 4.6% received naloxone. Overall, 98.5% high-risk patients did not received naloxone, despite many interactions with the healthcare system including: 88,618 hospitalizations, 229,680 emergency department (ED) visits, 298,058 internal medicine visits, and 568,448 family practice visits. In the highest risk group, 96% of patients had at least 1 ED visit.

Conclusions

Within our study population, patients at high risk for opioid overdose rarely received prescriptions for naloxone despite numerous interactions with the healthcare system. Healthcare visits remain a missed opportunity to provide naloxone. Efforts to support prescribing in emergency, inpatient, and in outpatient settings represent an important opportunity to improve naloxone access. This may include policies such as the implementation of naloxone standing orders, protection from civil liability for naloxone dispensing and use, and the addition of co-prescribing recommendations to prescription opioid labeling. Overall, prescribing naloxone as a standard-of-care for high-risk patients addresses a critical patient-care need and helps advocate for this particularly vulnerable group.

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