The vast majority of people who are at high risk of opioid overdose are not prescribed the naloxone they may one day need to save their lives, according to the results of a new study published in JAMA. In fact, the researchers found that only about 1.5% of high-risk patients receive such a prescription, despite multiple opportunities.

Sarah Follman and associates from the University of Chicago performed a retrospective study in which they analyzed data from the Truven Health MarketScan Research Database. The researchers reviewed information on subjects who had ICD-10 codes associated with opioid use, misuse, dependence, and overdose from Oct. 1, 2015, through Dec. 31, 2016.

The team identified 138,108 high-risk individuals as having interacted with the healthcare system nearly 1.2 million times. The interactions included 88,618 hospitalizations, 229,680 emergency department (ED) visits, 568,448 family practice visits, and 298,058 internal medicine visits.

Despite the high number of interaction with medical professionals, clinicians prescribed naloxone to only 2,135 of the 138,108 high-risk individuals during the study period.

At an odds ratio (OR) of 2.32, patients previously diagnosed with both opioid misuse/dependence and overdose were more likely to receive naloxone than were those who had only a history of dependence. Furthermore, those with a history of only overdose alone without a history of misuse were less likely to receive a prescription for naloxone, as were patients with a history of only misuse without overdose.

In their discussion, the authors of the study called this "surprising," noting "prior overdose is the strongest predictor of subsequent overdose and overdose death."

The researchers found that other factors could significantly reduce a patient’s odds of receiving a naloxone prescription. These factors included being from the West (OR 0.85) or Midwest (OR 0.62), or being 30 to 44 years of age (OR 0.72).

Factors that increased the odds of receiving a naloxone prescription included medication-assisted therapy (OR 1.68), visiting a detoxification facility (OR 1.51), receiving other treatment for substance use disorder (OR 1.16), or receiving outpatient care from a pain specialist (OR 1.57), psychologist (OR 1.49), or surgeon (OR 1.19).

The researchers suggest that health care visits are missed opportunities for providing naloxone. Nearly one-third of the cohort had at least one hospital admission, yet the provision of naloxone was only associated with having three or more hospitalizations during the study period. Similarly, slightly more than half had at least one ED visit during the period, yet only those with three or more ED visits were likely to receive the drug.

The authors of the study acknowledged that the results might underestimate the distribution and use of naloxone, as patients may get the lifesaving drug through private programs that do not bill insurance companies. The findings may not reflect patients covered by Medicaid or some Medicare plans, and the uninsured.

The researchers concluded by saying that most patients at high risk of opioid overdose do not receive a prescription to naloxone through direct prescribing. "Clinicians can address this gap by regularly prescribing naloxone to eligible patients. To address barriers to prescribing, hospital systems and medical schools can support clinicians by improving education on screening and treating substance use disorders, clarifying legal concerns, and developing policies and protocols to guide implementation of increased prescribing. Health care systems can also create or strengthen processes to encourage naloxone prescribing."

Recommendations for Naloxone Prescriptions from Health and Human Services

The Health and Human Services suggests prescribing naloxone for patients who:

• Are receiving opioids at a dosage of 50 morphine milligram equivalents (MME) or more daily.
• Have respiratory conditions such as obstructive sleep apnea or chronic obstructive pulmonary disease (COPD).
• Have been prescribed benzodiazepines.
• Have a non-opioid substance use disorder, has reported excessive alcohol use, or have a mental health disorder.
• Use heroin, illicit synthetic opioids.
• Misuse prescription opioids.
• Use other illicit drugs, including methamphetamine and cocaine, which may be contaminated with fentanyl or other illicit synthetic opioids.
• Are currently undergoing treatment for opioid use disorder, including medication-assisted treatment.
• Have a history of opioid misuse and a recent release from incarceration or another controlled setting that has reduced his or her tolerance to opioids.