Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain

Abstract

Background: Unintentional overdose involving opioid analgesics is a leading cause of injury-related death in the United States.

Objective: To evaluate the feasibility and effect of implementing naloxone prescription to patients prescribed opioids for chronic pain.

Design: 2-year nonrandomized intervention study.

Setting: 6 safety-net primary care clinics in San Francisco, California.

Participants: 1985 adults receiving long-term opioid therapy for pain.

Intervention: Providers and clinic staff were trained and supported in naloxone prescribing.

Measurements: Outcomes were proportion of patients prescribed naloxone, opioid-related emergency department (ED) visits, and prescribed opioid dose based on chart review.

Results: 38.2% of 1985 patients receiving long-term opioids were prescribed naloxone. Patients prescribed higher doses of opioids and with an opioid-related ED visit in the past 12 months were independently more likely to be prescribed naloxone. Patients who received a naloxone prescription had 47% fewer opioid-related ED visits per month in the 6 months after receipt of the prescription (incidence rate ratio [IRR], 0.53 [95% CI, 0.34 to 0.83]; P = 0.005) and 63% fewer visits after 1 year (IRR, 0.37 [CI, 0.22 to 0.64]; P < 0.001) compared with patients who did not receive naloxone. There was no net change over time in opioid dose among those who received naloxone and those who did not (IRR, 1.03 [CI, 0.91 to 1.27]; P = 0.61).

Limitation: Results are observational and may not be generalizable beyond safety-net settings.

Conclusion: Naloxone can be coprescribed to primary care patients prescribed opioids for pain. When advised to offer naloxone to all patients receiving opioids, providers may prioritize those with established risk factors. Providing naloxone in primary care settings may have ancillary benefits, such as reducing opioid-related adverse events.

Primary funding source: National Institutes of Health.

Appendix Figure 1

Checklist for clinic staff to train patients receiving naloxone

Appendix Figure 2

Email template to remind providers about naloxone prescribing

Appendix Figure 2

Email template to remind providers about naloxone prescribing

Appendix Figure 3

Naloxone for Opioid Safety patient brochure

Appendix Figure 4

Informational sheet for pharmacists on ordering, dispensing, counseling, and billing for naloxone

Appendix Figure 5

Expected number of opioid-related emergency department visits per month by receipt of naloxone prescription, stratified by clinic *Expected number of emergency department visits per month among two patients, one who received a naloxone prescription and another who did not, both with mean values of all covariates and stratified by clinic. †For both trajectories, time was uniformly centered on April 2014, the median time of receipt of naloxone prescription during the study period among patients who received naloxone.

Appendix Figure 6

Expected opioid dose (MEQ – morphine equivalent daily dose in milligrams) by receipt of naloxone prescription, stratified by clinic *Expected morphine equivalent daily dose in milligrams among two patients, one who received a naloxone prescription and another who did not, both with mean values of all covariates and stratified by clinic † For both trajectories, time was uniformly centered on April 2014, the median time of receipt of naloxone prescription during the study period among patients who received naloxone.

Figure 1

Expected number of opioid-related emergency department visits per month by receipt of naloxone prescription *Expected number of emergency department visits per month calculated for two patients, one who received a naloxone prescription and another who did not, both with mean values of all covariates † For both trajectories, time was uniformly centered on April 2014, the median month of receipt of naloxone prescription during the study period among patients who received naloxone.

Figure 2

Expected opioid dose (MEQ – morphine equivalent daily dose in milligrams) by receipt of naloxone prescription *Expected morphine equivalent daily dose in milligrams among two patients, one who received a naloxone prescription and another who did not, both with mean values of all covariates † For both trajectories, time was uniformly centered on April 2014, the median month of receipt of naloxone prescription during the study period among patients who received naloxone.