MME indicates morphine milligram equivalents.
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Jones CM, Compton W, Vythilingam M, Giroir B. Naloxone Co-prescribing to Patients Receiving Prescription Opioids in the Medicare Part D Program, United States, 2016-2017. JAMA. 2019;322(5):462–464. doi:10.1001/jama.2019.7988
Co-prescription of naloxone to patients receiving long-term opioid therapy provides an opportunity to expand naloxone access to patients at risk for opioid overdose.1 The 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain recommends that clinicians consider co-prescribing naloxone to patients at increased overdose risk, such as those receiving daily opioid dosages of 50 morphine milligram equivalents (MME) or greater or those receiving benzodiazepines.2 In 2017, Vermont mandated naloxone co-prescribing when patients receive opioids at dosages of 90 MME/d or greater or concomitant benzodiazepines,3 and Virginia mandated co-prescribing when patients receive opioids at dosages of 120 MME/d or greater or concomitant benzodiazepines.4 To date, the extent of naloxone co-prescribing is unknown. We used Medicare Part D data to compare national and state rates of naloxone co-prescribing in 2016-2017.
Dispensed prescriptions for opioids, benzodiazepines, and naloxone were identified by National Drug Codes in the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse, a census of Medicare Part D data. Patients filling an opioid prescription in 2016 or 2017 and having Part D coverage the entire year in which the opioid was filled were included; hospice patients were excluded.
Naloxone co-prescribing was defined as a naloxone claim within 7 days of any prescription opioid claim. No standard definition for naloxone co-prescription exists. While 66% of naloxone prescriptions were dispensed within 1 day of an opioid, the 7-day co-prescription time frame allowed for insurance coverage issues (eg, prior authorization or naloxone formulation substitutions) to be resolved. Maximum daily MME during the year was calculated using standard MME conversion factors.5 We calculated 2016 and 2017 national and state naloxone co-prescription rates per 1000 patients receiving opioids across 7 categories: (1) any opioid amount; (2) less than 50 MME/d; (3) 50 to 89 MME/d; (4) 90 MME/d or greater; (5) any opioid and benzodiazepine; (6) receiving opioids and benzodiazepines for 300 days per year or longer; and (7) receiving opioids and benzodiazepines for 300 days per year or longer and opioid dosage of 90 MME/d or greater. This study was exempt from institutional review board review under 45 CFR §46.104(d)(4).
Nationally, in 2016 and 2017, a total of 12 778 098 and 12 569 263 Medicare Part D beneficiaries, respectively, received at least 1 opioid prescription and 19 758 and 58 092 received naloxone within 7 days of an opioid prescription. Rates for naloxone co-prescription with any opioid increased from 1.5 per 1000 patients in 2016 to 4.6 per 1000 in 2017 (Figure). Rates increased across all categories. Patients receiving opioids and benzodiazepines for 300 days per year or longer with a maximum of 90 MME/d or greater had the highest rates (38.5 per 1000 in 2017).
In 2017, state rates of naloxone co-prescribing with any opioid ranged from 0.7 per 1000 in Nebraska to 33.0 per 1000 in Virginia (Table). Virginia and Vermont had the highest rates across all categories in 2017 and experienced the largest absolute and percentage increases between 2016 and 2017. The rate for Virginia increased from 1.2 to 33.0 per 1000, an absolute increase of 31.8 per 1000 (2650% increase). The rate for Vermont increased from 2.0 to 32.3 per 1000, an absolute increase of 30.3 per 1000 (1515% increase).
Naloxone co-prescribing in Medicare Part D increased nationally and across states between 2016 and 2017. However, only a minority of patients were co-prescribed naloxone. Consistent with guideline recommendations, the highest rates were among patients with high opioid doses and those receiving benzodiazepines. This was especially true for Virginia and Vermont, states implementing naloxone co-prescribing regulations in 2017.
Limitations include that findings may not generalize to non–Medicare Part D populations. Data on naloxone co-prescribing would not be captured if patients paid cash or received naloxone outside of Medicare Part D, or if clinicians prescribed naloxone but patients did not fill the prescription.
Clinicians, pharmacists, and patients should be educated about the circumstances necessitating naloxone co-prescribing. Health systems can pursue proactive approaches such as implementing co-prescribing prompts into electronic health records.6 Implementation of state-level policies requiring naloxone co-prescribing to high-risk patients may have large effects on clinical practice. Additional research is needed to improve understanding of patient and clinician barriers to naloxone and examine the benefits, cost-effectiveness, and unintended consequences of naloxone co-prescribing.
Accepted for Publication: May 22, 2019.
Corresponding Author: Christopher M. Jones, PharmD, DrPH, MPH, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4700 Buford Hwy, Atlanta, GA 30341 (email@example.com).
Author Contributions: Dr Jones 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: Jones, Compton, Giroir.
Acquisition, analysis, or interpretation of data: Jones, Compton, Vythilingam.
Drafting of the manuscript: Jones, Giroir.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Jones.
Administrative, technical, or material support: Jones, Vythilingam.
Conflict of Interest Disclosures: Dr Compton reported owning stock in General Electric, 3M, and Pfizer. No other disclosures were reported.
Disclaimer: The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the Centers for Disease Control and Prevention, National Institutes of Health, or the US Department of Health and Human Services.
Additional Contributions: We thank Kevin Hodges, BS, MSIS, Keri Apostle, MPH, Anna Bonelli, MURP, and Devon Trolley, MHA, all from the Centers for Medicare & Medicaid Services, for their assistance with data collection and access. These individuals were not compensated for their contributions.