Naloxone prescriptions from the emergency department: An initiative in evolution

Emergency Department Take-Home Naloxone Improves Access Compared with Pharmacy-Dispensed Naloxone

BACKGROUND

Opioid overdose is a major cause of mortality in the United States. In spite of efforts to increase naloxone availability, distribution to high-risk populations remains a challenge.

OBJECTIVE

To assess the effects of multiple different naloxone distribution methods on patient obtainment of naloxone in the emergency department (ED) setting.

METHODS

Naloxone was provided to patients in three 12-month phases between February 2020 and February 2023. In Phase 1, physicians could offer patients electronic prescriptions, which were filled in a nearby in-hospital discharge pharmacy. In Phase 2, physicians directly provided patients with take-home naloxone at discharge. In Phase 3, distribution was expanded to allow ED staff to hand patients take-home naloxone at time of discharge. The total number of prescriptions, rate of prescription filling, and amount of take-home naloxone kits provided to patients were then statistically analyzed using 95% confidence intervals (CI) and chi-squared testing.

RESULTS

In Phase 1, 348 naloxone prescriptions were written, with 133 (95% CI 112.5-153.5) filled. In Phase 2, 327 (95% CI 245.5-408.5) take-home naloxone kits were given to patients by physicians. In Phase 3, 677 (95% CI 509.5-844.5) take-home naloxone kits were provided to patients by ED staff. There were statistically significant increases in naloxone distribution from Phase 1 to Phase 2, and Phase 2 to Phase 3.

CONCLUSIONS

Take-home naloxone increases access when compared with naloxone prescriptions in the ED setting. A multidisciplinary approach combined with the removal of regulatory and administrative barriers allowed for further increased distribution of no-cost naloxone to patients.

Treatment Updates for Pain Management and Opioid Use Disorder

The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.

Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project

BACKGROUND

Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing.

METHODS

We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing.

RESULTS

The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52).

CONCLUSIONS

A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.

Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose

BACKGROUND

Emergency department (ED) patients with nonfatal opioid overdose are at high risk for subsequent fatal overdose, yet ED programs aimed at reducing harm from opioid use remain underdeveloped.

OBJECTIVES

The objective was to pilot a statewide ED take-home naloxone program and improve the care of patients with opioid use disorder (OUD) and risky drug use through training and interprofessional network building.

METHODS

Nine hospital EDs with pharmacy, nurse, and physician champions were recruited, surveyed, and trained. Take-home naloxone rescue kits were developed, disseminated, and tracked. Two overdose prevention summits were convened prior to the COVID pandemic, and two X-waiver training courses aimed at emergency physicians and advanced practice providers were arranged, both in person and virtual.

RESULTS

A total of 872 naloxone rescue kits were distributed to ED patients at risk of opioid overdose during the first phase of this project, and more than 140 providers were trained in the use of medications for OUD in acute care settings.

CONCLUSIONS

A statewide ED take-home naloxone program was shown to be feasible across a range of different hospitals with varying maturity in preexisting OUD resources and capabilities. Future work will be aimed at both expanding and measuring the effectiveness of this work.

Assessment of Patient-Reported Naloxone Acquisition and Carrying With an Automated Text Messaging System After Emergency Department Discharge in Philadelphia

IMPORTANCE

A central tenet of harm reduction and prevention of opioid overdose deaths is the distribution and use of naloxone. Patient-centered methods that investigate naloxone acquisition and carrying can guide opioid overdose education and naloxone distribution efforts.

OBJECTIVE

To assess patients' self-reported naloxone acquisition and carrying after an emergency department (ED) encounter using automated text messaging.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study investigated self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia, Pennsylvania. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record provided informed consent after ED discharge, and data were collected prospectively using text messaging from October 10, 2020, to March 19, 2021. Patients who did not respond to the survey or who opted out were excluded.

EXPOSURE

Automated text message-based survey after ED discharge for patients who were prescribed or dispensed naloxone.

MAIN OUTCOMES AND MEASURES

The primary outcome was patient-reported naloxone acquisition, carrying, and use. Descriptive statistics were used to summarize patient demographic characteristics.

RESULTS

Of 205 eligible patients, 41 (20.0%) completed the survey; of those patients, the mean (SD) age was 39.5 (13.7) years, and 21 (51.2%) were women. Fifteen (36.6%) had a personal history of being given naloxone after an overdose. As indicated by the ED record, 27 participants (65.9%) had naloxone dispensed in the ED, and 36 (87.8%) self-reported acquiring naloxone during or after their ED visit. Twenty-four participants (58.5%) were not carrying naloxone in the week before their ED visit. Twenty participants (48.8%) were carrying naloxone after the ED visit, and 27 (65.9%) reported planning to continue carrying naloxone in the future. Of the 24 individuals (58.5%) not carrying naloxone before their ED encounter, 13 (54.2%) reported planning to continue carrying naloxone in the future.

CONCLUSIONS AND RELEVANCE

In this cohort study of adult patients dispensed or prescribed naloxone from the ED, most reported acquiring naloxone on or after discharge. The ED remains a key point of access to naloxone for individuals at high risk of opioid use and overdose, and text messaging could be a method to engage and motivate patient-reported behaviors in enhancing naloxone acquisition and carrying.

Adult emergency department naloxone education and prescription program: Video and pamphlet education comparison

OBJECTIVES

This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format.

METHODS

This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods.

RESULTS

Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53.

CONCLUSIONS

There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.

Point-of-care naloxone distribution in the emergency department: A pilot study

PURPOSE

Opioid overdose education and naloxone distribution (OEND) for use by laypersons has been shown to be safe and effective, but implementation in the emergency department (ED) setting is challenging. Recent literature has shown a discouragingly low rate of obtainment of naloxone that is prescribed in the ED setting. We conducted a study to evaluate the feasibility of point-of-care (POC) distribution of naloxone in an ED, hypothesizing a rate of obtainment higher than prescription fill rates reported in previous studies.

SUMMARY

A multidisciplinary team of experts, including pharmacists, physicians, nurses, and case management professionals used an iterative process to develop a protocol for POC OEND in the ED. The protocol includes 5 steps: (1) patient screening, (2) order placement in the electronic health record (EHR), (3) a patient training video, (4) dispensing of naloxone kit, and (5) written discharge instructions. The naloxone kits were assembled, labeled to meet requirements for a prescription, and stored in an automated dispensing cabinet. Two pharmacists, 30 attending physicians, 65 resident physicians, and 108 nurses were trained. In 8 months, 134 orders for take-home naloxone were entered and 117 naloxone kits were dispensed, resulting in an obtainment rate of 87.3%. The indication for take-home naloxone kit was heroin use for 61 patients (92.4%).

CONCLUSION

POC naloxone distribution is feasible and yielded a rate of obtainment significantly higher than previous studies in which naloxone was prescribed. POC distribution can be replicated at other hospitals with low rates of obtainment.

Take-Home Naloxone and the Need for a Publicly Funded Naloxone Supply

The opioid crisis continues to exact a heavy toll on the United States, and overdose deaths have only increased during the current global pandemic. One effective intervention to reduce overdose deaths is to distribute the opioid antagonist naloxone directly to persons actively using opioids (ie, "take-home naloxone"), especially at touchpoints with the potential for significant impact such as emergency departments and jails. A number of hospital emergency departments have recently sought to implement individual take-home naloxone programs; however, programmatic success has been inconsistent due primarily to the inability to secure reliable funding for a naloxone supply. In this commentary, we establish the argument for a publicly funded naloxone supply to support take-home naloxone distribution in emergency department settings. We posit that the complex billing and reimbursement system for medication dispensing is impossibly burdensome during emergency care for an acute opioid overdose, and that the mounting death toll from this public health crisis demands a strong commitment to harm reduction. A publicly financed naloxone supply would demonstrate this commitment and make a measurable impact in saving lives. Ultimately, provision of naloxone should be coupled with other comprehensive treatment services and medications for opioid use disorder to meaningfully reduce harms associated with opioid use.

Take-Home Naloxone Program Implementation: Lessons Learned From Seven Chicago-Area Hospitals

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.

Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review

BACKGROUND

Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.

METHODS

We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.

RESULTS

Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97).

CONCLUSIONS

In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

Naloxone Deserts in NJ Cities: Sociodemographic Factors Which May Impact Retail Pharmacy Naloxone Availability

INTRODUCTION

Retail pharmacies in NJ are permitted to dispense naloxone without a prescription. However, not all pharmacies have participated in this effort, and it is not clear what factors may impact its availability. We sought to determine the naloxone availability of select NJ cities and what sociodemographic factors are associated with its availability. We compared naloxone availability in retail pharmacies to median household income, population, and the prevalence of opioid-related hospital visits (ORHV).

METHODS

All retail pharmacies in ten New Jersey cities were surveyed by phone in February-July 2017. The standardized survey instrument asked scripted questions to each pharmacist concerning the stocking of naloxone for dispensing. Median household income data and population data for each city were obtained from census.gov . Opioid-related hospital visits were obtained through the NJ SHAD database and the prevalence of ORHV was calculated. Naloxone availability was compared to median household income, population, and ORHV using Spearman's rho and Pearson's correlation.

RESULTS

Naloxone availability in the 90 retail pharmacies we surveyed was 31% and ranged from 15.38 to 66.67% by city. An increase in median household income indicated more pharmacy naloxone availability. An increase in population indicated less pharmacy naloxone availability. While no significant relationship existed between ORHV and pharmacy naloxone availability, we did identify individual cities with severe opioid-related public health concerns with limited naloxone access.

CONCLUSIONS

Naloxone deserts exist in select high-risk New Jersey cities, and pharmacy naloxone availability may be positively related to median household income and negatively related to population.