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LetterPolicy Forum

Naloxone-Prescribing Practices

A Missed Opportunity

Shane Stone, Erin Barnes, Christopher J McLouth and Candice J. McNeil
North Carolina Medical Journal September 2018, 79 (5) 343-344; DOI: https://doi.org/10.18043/ncm.79.5.343
Shane Stone
medical student, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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  • For correspondence: snstone@wakehealth.edu
Erin Barnes
instructor, Wake Forest Health Sciences, Department of Medicine, Section on Infectious Diseases, Wake Forest University, Winston-Salem, North Carolina
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Christopher J McLouth
department of biostatistics, Wake Forest Health Sciences, Wake Forest University, Winston-Salem, North Carolina
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Candice J. McNeil
assistant professor, Wake Forest Health Sciences, Department of Medicine, Section on Infectious Diseases, Wake Forest University, Winston-Salem, North Carolina
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To the Editor—We read with interest your recent issue describing the statewide care efforts for opioid-addicted patients, particularly Khatiwoda et al.'s article assessing naloxone kit use [1]. Given the Surgeon General's emphasis on naloxone in combatting the opioid epidemic [2], we assessed the opioid and naloxone-prescribing practices at Wake Forest Baptist Health System, an 885-bed tertiary referral center in northwest North Carolina. We assessed 2 groups for whom naloxone should be considered: those with an opioid abuse disorder and those prescribed opioid doses ≥ 50 morphine milligram equivalents (MME)/day. Doses ≥ 50 MME/day have been associated with increased overdose risk [3].

To determine patients at risk for opioid addiction, we extracted patients aged 18 and older with ICD codes of opioid use disorder, intoxication, withdrawal, and/or unspecified opioid-related disorder from January 1, 2012, through January 1, 2017. We then extracted all opioid prescriptions written during this same period, converted them to MME, and flagged prescriptions of ≥ 50 MME/day as “at risk [4].” Intravenous, bulk-form, and prescriptions with incalculable total opioid value were excluded. Finally, we pulled all naloxone prescriptions during this period.

During the study period 2,214,438 opiate prescriptions were written for 159,746 individuals. 220,998 (0.1%) prescriptions for 8,992 (0.06%) individuals qualified for naloxone due to receiving an “at risk” prescription. The most common opiates prescribed (by proportion of total prescriptions) were oxycodone (52.02%), hydrocodone (38.02%), and morphine (3.69%). Oxycodone (143,707), morphine (29,304), and hydromorphone (20,173) had the highest total number of naloxone-eligible prescriptions while methadone (51.59%), oxymorphone (39.40%), and morphine (32.65%) had the highest proportion of naloxone-qualifying prescriptions. Recipients averaged 47.2 years of age (standard deviation = 20.8) and were 76% Caucasian and 17% African American; 3,936 patients had an opioid abuse ICD code during the study period. Combining these 3,936 patients with the 8,992 patients who received an “at-risk” prescription yielded an estimated 12,928 patients who qualified for naloxone, but only 4 (0.0003%) individuals received a prescription.

The limitations of our study include the potential for missed prescriptions and for overlap between the opioid prescription and opioid disorder group; however, multiple formulations of naloxone were assessed to minimize potential missing data. Additionally, it is possible that prescriptions were not captured if they were acquired utilizing the state's standing order for naloxone which allows patients to receive naloxone directly at a pharmacy without an individual prescription [5]. While the CDC's opioid and naloxone-prescribing guidelines and recommendations emerged in the last 2 years of our study period, the gap between the patients at risk and those with a naloxone prescription is striking. We are missing an important opportunity to impact this public health crisis through prescribing naloxone for opioid overdose prevention. Investigations to better understand the barriers and attitudes regarding naloxone prescribing are needed.

Acknowledgments

Funding was provided through the Wake Forest Center for Research on Substance Use and Addiction Grant. Additionally, the authors would like to acknowledge the statistical assistance of the Wake Forest Clinical and Translational Science Institute (WF CTSI), which is supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR001420.

Potential conflicts of interest. The authors have no relevant conflicts of interest.

  • ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

References

  1. ↵
    1. Khatiwoda P,
    2. Proeschold-Bell RJ,
    3. Meade CS,
    4. Park LP,
    5. Proescholdbell S
    Facilitators and barriers to naloxone kit use among opioid-dependent patients enrolled in medication assisted therapy clinics in North Carolina. N C Med J. 2018;79(3):149-155.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Adams J
    Surgeon General's Advisory on Naloxone and Opioid Overdose. Surgeon General website. https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html. Accessed June 27, 2018.
  3. ↵
    1. Dowell D,
    2. Haegerich TM,
    3. Chou R
    CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624-1645.
    OpenUrlCrossRefPubMed
  4. ↵
    1. U.S. Department of Health and Human Services
    Calculating Total Daily Dose of Opioids for Safer Dosage. In: CDC, ed2016.
  5. ↵
    North Carolina's Standing Order for Naloxone. 2016; https://www.naloxonesaves.org/north-carolinas-standing-order-for-naloxone/. Accessed July 5, 2018.
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North Carolina Medical Journal: 79 (5)
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Naloxone-Prescribing Practices
Shane Stone, Erin Barnes, Christopher J McLouth, Candice J. McNeil
North Carolina Medical Journal Sep 2018, 79 (5) 343-344; DOI: 10.18043/ncm.79.5.343

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Naloxone-Prescribing Practices
Shane Stone, Erin Barnes, Christopher J McLouth, Candice J. McNeil
North Carolina Medical Journal Sep 2018, 79 (5) 343-344; DOI: 10.18043/ncm.79.5.343
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