Trends in Filled Naloxone Prescriptions Before and During the COVID-19 Pandemic in the United States

Substance use, including opioid use, increased during the COVID-19 pandemic.¹ While overall emergency department visits decreased during the pandemic, nonfatal opioid overdose visits more than doubled, but few patients who overdosed on opioids received naloxone prescriptions on discharge.² Studies show that increased access to naloxone can reduce fatal overdoses.^3,4 In this study, we analyze the trends in filled naloxone prescriptions during the COVID-19 pandemic in the United States and compare these with trends in opioid prescriptions and overall prescriptions.

Through the COVID-19 Research Database,⁵ we used Symphony Health, a pharmacy claims database that includes 92% of national retail pharmacy claims, 71% of mail-order pharmacy claims, and 65% of specialty pharmacy activity, to examine the period from May 2019 to December 2020. We analyzed weekly trends in the number of patients filling naloxone prescriptions, opioid prescriptions, and all prescriptions from May 13, 2019, to December 20, 2020. We defined the prepandemic time period to be May 13, 2019, through the week of March 13, 2020, when a national emergency was declared for COVID-19 in the United States. We defined the pandemic period as beginning the following week and continuing through the end of the sample period. We used an interrupted time series design to quantify changes in the level and growth rate in weekly filled prescriptions before and during the pandemic. We stratified analyses by payer (Medicaid, Medicare, commercial, and cash). We excluded weeks with national holidays (Thanksgiving, Christmas, and New Year’s Day). We used linear regression models and log-linear regression models, where a P value ≤.05 was considered statistically significant and all tests were 2-tailed. Stata SE version 16 (StataCorp) was used for statistical analysis. This research was classified as exempt by the Beth Israel Deaconess Medical Center institutional review board and it followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. This study used only deidentified data and was classified as exempt from written informed consent by the Beth Israel Deaconess Medical Center institutional review board.

Trends in the average number of individuals filling prescriptions for naloxone, opioids, and any medication are summarized in the Figure. Abruptly in March 2020, the average number of individuals filling naloxone prescriptions per week declined in level by 361.09 individuals (95% CI, −499.56 to −222.62), which corresponds to a 26.32% reduction (Table). This exceeded the decline in the number of individuals filling prescriptions for any medication (−14.76%) and for opioid medications (−8.71%). Since March 2020, there was no statistically significant recovery in naloxone prescriptions (change in weekly growth rate: 0.36%; 95% CI, −0.17% to 0.88%), indicating that the number of individuals filling naloxone prescriptions has remained low throughout the pandemic. The weekly growth rates for individuals filling prescriptions for opioids and for any prescription have declined since March 2020. Individuals with Medicare and commercial insurance had a statistically significant decline in filling naloxone prescriptions at the start of the pandemic (−34.15% and −31.20%, respectively), while patients with Medicaid or cash payment had no statistically significant change during the pandemic.

These findings indicate that individuals on Medicare and commercial insurance may be experiencing decreased access to naloxone during the COVID-19 pandemic. The decline is not explained by a decline in opioid prescriptions, where naloxone coprescription is recommended, as opioid prescriptions only decreased by 8.71% in March 2020, less than all prescriptions and much less than naloxone prescriptions. Limitations of this study include that we are only able to account for naloxone prescriptions filled at retail pharmacies and not naloxone kits distributed from other sources, such as syringe service programs.⁶ Our study identifies an urgent gap in necessary access to medication for individuals on Medicare and commercial insurance during the pandemic. Continuing to increase naloxone distribution in densely populated areas and via mail order and delivery through community-based organizations could help to mitigate some of the reductions in naloxone distribution via pharmacies and could reduce some of the increases in fatal opioid overdoses during the COVID-19 pandemic.

Accepted for Publication: March 12, 2021.

Published: May 14, 2021. doi:10.1001/jamahealthforum.2021.0393

Correction: This article was corrected on June 25, 2021, to add volume, issue, and page numbers to the first reference.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 O’Donoghue AL et al. JAMA Health Forum.

Corresponding Author: Ashley L. O’Donoghue, PhD, Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (aodonogh@bidmc.harvard.edu).

Author Contributions: Dr O’Donoghue had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O’Donoghue, Biswas, Anderson, Talmor, Stevens.

Acquisition, analysis, or interpretation of data: O'Donoghue, Dechen, Anderson, Punnamaraju.

Drafting of the manuscript: O’Donoghue, Biswas, Talmor, Stevens.

Critical revision of the manuscript for important intellectual content: O’Donoghue, Dechen, Anderson, Punnamaraju, Stevens.

Statistical analysis: O’Donoghue, Punnamaraju.

Obtained funding: O’Donoghue, Stevens.

Administrative, technical, or material support: Dechen, Punnamaraju.

Supervision: Stevens.

Conflict of Interest Disclosures: Dr O’Donoghue reported financial support from Google.org (unrestricted philanthropic funds) during the conduct of the study. No other disclosures were reported.

Funding/Support: Dr O’Donoghue, Ms Dechen, Ms Talmor, Ms Punnamaraju, and Dr Stevens are funded by an unrestricted philanthropic gift from Google.org.

Role of the Funder/Sponsor: Google.org had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: The data, technology, and services used in the generation of these research findings were generously supplied pro bono by the COVID-19 Research Database partners, who are acknowledged at https://covid19researchdatabase.org.