Coprescribing Naloxone With an Opioid Aids Chronic Pain

Megan Brooks

June 28, 2016

Coprescribing naloxone (multiple brands) to primary care patients who take opioid analgesics for chronic pain is feasible and may reduce opioid-related trips to the emergency department (ED), new research suggests.

Unintentional opioid overdose is now a leading cause of injury-related death in the United States. Targeting the distribution of naloxone, a fast-acting drug that reverses opioid overdose, to those likely to suffer an opioid overdose ― mainly illicit drug users ― has reduced opioid overdose deaths in communities where this practice has been implemented. Limited research suggests that this practice could be extended to primary care patients receiving long-term opioid therapy for pain.

To investigate further, Phillip Coffin, MD, from the University of California, San Francisco, and colleagues assessed the feasibility of introducing and scaling up naloxone coprescribing at six safety-net primary care clinics in San Francisco. Participating providers and clinic staff were trained and supported in how to educate patients about opioid overdose and to prescribe naloxone.

Among 1985 patients receiving long-term opioid therapy for chronic pain, 38.2% were prescribed naloxone during the study period. Providers were more apt to prescribe naloxone to patients taking higher doses of opioids and to those who had had an opioid-related ED visit in the past year.

"In the absence of guideline-based indications for naloxone coprescribing, these may be reasonable metrics upon which to prioritize prescription of naloxone," Dr Coffin and colleagues say. Recent guidelines from the US Centers for Disease Control and Prevention on opioid prescribing recommend considering prescribing naloxone to patients with a history of overdose or substance use disorder, to those who are taking an opioid at a dose greater than 50 MEQ (morphine equivalent daily dose in milligrams), or to patients who are concurrently receiving a benzodiazepine, they point out.

The study also found that patients who were coprescribed naloxone 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% confidence interval [CI], 0.34 - 0.83; P = .005) and 63% fewer visits after 1 year (IRR, 0.37; CI, 0.22 - 0.64; P < .001) relative to their peers who were not given a prescription for naloxone. There was no net change over time in opioid dose among patients who received naloxone and those that did not (IRR, 1.03; CI, 0.91 - 1.27; P = .61).

The researchers caution that the results are observational and may not be generalizable beyond safety-net settings.

The findings were published online June 28 in Annals of Internal Medicine.

Substantial Step Forward

The authors of an accompanying editorial say this study is a "substantial step forward" in demonstrating the feasibility of coprescription of naloxone in primary care settings and provides a "practical starting point for future, broader implementation efforts."

Alexander Y. Walley, MD, and Traci C. Green, PhD, of Boston University School of Medicine in Massachusetts, note that the mechanism by which naloxone reduced ED visits needs clarification.

"The educational component of the intervention may have reduced ED visits by altering risk behaviors, thus preventing overdoses in the first place. Alternatively, having naloxone available may have prevented the need for an ED visit when an overdose did occur. Receiving a naloxone rescue kit may have served as tangible reinforcement of overdose prevention messages, though this warrants further study," they write.

"If the substantial reductions in opioid-related ED visits observed at 6 and 12 months prove to be robust in other populations, this intervention will benefit patients and health systems," Dr Walley and Dr Green conclude.

The study was funded by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online June 28, 2016. Abstract, Editorial

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