Despite Guidelines, Few Patients Prescribed Long-term Opioid Therapy Also Receive Naloxone

US guidelines recommend prescribing naloxone, an opioid antagonist that reverses opioid overdose, to patients prescribed long-term opioid therapy (LTOT). This retrospective study used pharmacy claims data to examine how frequently naloxone was co-prescribed with LTOT and whether individual or community characteristics were associated with co-prescribing. A large database from US commercial pharmacies included 6 million LTOT treatment episodes (defined as filling opioid prescriptions for ≥90 days) among 5 million unique individuals in 2017–2018. Individual and community characteristics included age, sex, high-dose LTOT (≥90 milligrams morphine equivalent daily), benzodiazepine co-prescribing, insurance type, prescriber specialty, and county-level urbanicity, overdose rate, and poverty.

• Overall, naloxone was co-prescribed in only 2.3% of LTOT treatment episodes.
• Naloxone co-prescribing was associated with receiving high-dose opioid prescriptions (adjusted odds ratio [aOR], 3.19) and benzodiazepine medications (aOR, 1.12), although co-prescribing remained uncommon during these treatment episodes (7.3% and 3.5%, respectively).
• Co-prescribing was higher when Medicare or Medicaid was the payer (aOR, 1.48 and 1.87, respectively), versus other insurance or cash payment (aOR, 0.81 and 0.77, respectively).
• Naloxone co-prescribing increased with age up the 46–55 year range, but then was lower in older age groups.
• Co-prescribing was more common in LTOT treatment episodes from counties with high (versus low) overdose rates and urban (versus rural) counties.

Comments: Many patients who should receive naloxone from pharmacies do not. Community-based naloxone distribution programs remain critically important, but clinicians who prescribe LTOT also need to do their part. Avoiding known risks, such as prescribing LTOT in high doses or with benzodiazepines, is one step; prescribing naloxone, which is safe and simple to administer, could also prevent accidental opioid overdose deaths. Measures that may help increase co-prescribing include electronic prompts when prescribing, automatic dispensing of naloxone with opioid prescriptions and reducing cost barriers.

Aaron D. Fox, MD

Reference: Stein BD, Smart R, Jones CM, et al. Individual and community factors associated with naloxone co-prescribing among long-term opioid patients: a retrospective analysis. J Gen Intern Med. 2021;10.1007/s11606-020-06577-5.