28 Jun Prescribing Naloxone To Patients on Chronic Opioids Reduces ER Visits for Opioid Concerns
MedicalResearch.com Interview with:
Phillip O. Coffin, MD, MIA
Director of Substance Use Research
San Francisco Department of Public Health
Assistant Professor, Division of HIV, ID & Global Health
University of California, San Francisco
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: San Francisco has a longstanding naloxone distribution program that primarily works out of syringe exchange programs and is temporally associated with a substantial decline in opioid overdose death due to heroin or involving injection drug use. Over 90% of opioid overdose deaths from 2010-2012 were due to prescription opioids in the absence of heroin, and most of those decedents were prescribed opioids in primary care settings. Based on these data, as well as anecdotal reports from sites such as U.S. Army Fort Bragg in North Carolina – where providing naloxone to pain patients appeared to be associated with a radical decline in opioid overdose admissions to the emergency department – we implemented a naloxone prescribing program in the safety net primary care clinics.
We recommended that providers offer naloxone to all patients who used opioids on a regular basis, or were otherwise at risk for experiencing or witnessing an opioid overdose, although we only measured outcomes related to patients who were prescribed opioids for chronic pain. We also recommended that providers avoid the term “overdose” as that term does not properly reflect the epidemiology of opioid poisoning and is interpreted by many to mean intentionally consuming a large amount of opioids; instead we recommended saying things like: “Opioids can cause bad reactions where you stop breathing or can’t be woken up.” Providers prescribed mostly the jerry-rigged nasal device, with the atomizer and a brochure dispensed at clinic and the naloxone picked up at the patients’ usual pharmacies, to approximate real-world medical practice.
MedicalResearch.com: What are the main findings?
Response: The primary goal of the study was to see if we could successfully prescribe naloxone to patients taking opioids for chronic pain in a primary care setting. There actually were no data to support even the feasibility of this intervention. We found that it was feasible, although there was substantial variability in provider uptake of the intervention, such that 38.2% of patients eventually got naloxone, and those who were on higher doses or had prior opioid-related emergency department visits were more likely to get a naloxone prescription. This study took place from 2013-2015, prior to any national recommendations to co-prescribe naloxone, which may have limited provider uptake.
We were not powered to measure a decline in mortality, however we did find in a well-controlled analysis that receiving a naloxone prescription was associated with a substantial decline in opioid-related visits to the emergency department. There were other elements to this study, including interviews with patients, that suggest the reason for this decline may have been an improved recognition of the risks of opioid medications.
While patients overall had a reduced opioid dose during the study, we found no clear association of naloxone receipt on prescribed opioid dose.
MedicalResearch.com: What should readers take away from your report?
Response: Prescribing naloxone to primary care patients prescribed opioids for chronic pain is feasible, well-received, associated with reduced use of the emergency department for opioid-related concerns, and not associated with increased use of prescribed opioids.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: The suggestion from our data that prescribing naloxone may impact opioid use such that patients have fewer related emergency department visits is exciting and opens the door to further studies aiming to maximize the benefits of naloxone prescribing.
MedicalResearch.com: Is there anything else you would like to add?
Response: The Centers for Disease Control and Prevention now recommend offering naloxone to some patients on opioid therapy for chronic pain. These data certainly support that approach and suggest that prescribing naloxone is a critical element of the larger package of opioid stewardship measures being adopted around the country. Since this study, the FDA has approved two new naloxone formulations intended for lay usage, making prescribing and dispensing the medication much easier within standard healthcare practice.
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Coffin PO, Behar E, Rowe C, Santos G, Coffa D, Bald M, et al. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. [Epub ahead of print 28 June 2016] doi:10.7326/M15-2771
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Last Updated on June 28, 2016 by Marie Benz MD FAAD