Alert Increased Take-Home Naloxone Prescriptions in ED

Tara Haelle

October 07, 2018

SAN DIEGO — A pop-up alert in the electronic medical records of patients at risk for an overdose can increase the distribution of take-home naloxone kits in the emergency department, new research shows.

Opioid-related visits to the emergency department continue to increase, so it is a critical access point for patients who could benefit from take-home naloxone kits, said researcher Ryan Marino, MD, from the University of Pittsburgh School of Medicine.

"There are still a lot of barriers to naloxone in the community," he said here at the American College of Emergency Physicians 2018 Scientific Assembly. "Pharmacies don't stock it," and there is a fear that it presents a "moral hazard."

But research has shown that most patients accept naloxone in the emergency department and that prescriptions for the take-home kit increase patient satisfaction.

There are also good data showing that, in addition to saving lives, naloxone "reduces overall healthcare costs, has overall societal benefits, improves community safety, and has an effect on age-adjusted workforce years," Marino reported.

There are still a lot of barriers to naloxone in the community.

Marino and his colleagues hypothesized that an electronic medical record pop-up alert to suggest take-home naloxone for overdose patients in the emergency department would increase prescriptions after an emergency intervention.

From July 2016 to April 2018, 4687 patients received a diagnosis of overdose in the 15 emergency departments participating in the study.

During that time, the number of pop-up alerts increased from 32 per month to 253 per month, "which reflects our opioid overdose volume," said Marino.

The average increase in take-home naloxone kits was 2% per month during the study period (P < .001). Urban academic sites with the highest volumes of overdose had the biggest increases, and nonacademic sites had the smallest.

But the increase was not uniform. A time-series analysis revealed an initial increase in prescriptions, but that leveled off. So the researchers expanded the key words used to trigger the pop-up alert to ensure that they were not missing overdose patients.

At implementation, the pop-up was prompted by the following terms: OPIOID, OPIOD, OPOID, HEROIN, OXYCODONE, HYDROCODONE, FENTANYL, and FENTANIL. In February 2018, it was revised to include additional terms: OD, XODX, XdetoxX, overdose, drug, /overdose, overdose/, polysubstance, XoverdoseX, detoxification, withdrawal, withdrawl, Narcan, naloxone, Methadone, detox, DETOX, DTX, /OD and OD/.

From 3 months before the alert was revised to 3 months after, prescriptions of take-home naloxone increased from 13.0% of discharged patients to 22.6%.

Before the pop-up was implemented, patients who were younger and white were significantly more likely to receive a take-home naloxone kit. After implementation, a patient's age, sex, or race had no significant effect on whether a kit would be prescribed.

"Everyone hates pop-up alerts in the electronic health record," Marino acknowledged, but this particular pop-up "literally saves lives."

"Overall, the pop-up alert was effective, low-cost, and low risk, which is something you can't really say about pretty much everything we do in medicine," he said.

The cost of a take-home naloxone kit was $75 each, which the hospital covered; the patient was not charged. Recent research shows that the number needed to treat with naloxone to save one person is six.

"That comes out to a cost of less than $500 to save someone's life," said Marino.

In addition to the pop-up alert, Marino and his colleagues worked to educate clinicians on the value of take-home naloxone and to debunk some of the misconceptions associated with its use. Still, some physicians simply would not prescribe it, regardless of the pop-up, he reported.

There was actually some sort of unconscious bias at play that looks like it got normalized with a standardized tool.

The impact of the alert on the bias in prescribing habits is "interesting and unexpected," said Sarah Shafer, MD, from the Baylor College of Medicine in Houston.

"There was actually some sort of unconscious bias at play that looks like it got normalized with a standardized tool," Shafer told Medscape News. "It makes you think about how EMRs could potentially address things like unconscious bias or systematic bias."

"I have mixed feelings," said Michael Repplinger, MD, PhD, from the University of Wisconsin–Madison. "I'm excited that it made a difference and a little disappointed it didn't make more of a difference."

Alert fatigue could be one factor at play in reducing the effectiveness of the pop-up, but another is the underlying bias some providers have about prescribing naloxone in the first place, he noted.

Research from implementation science suggests that two other interventions could improve rates of take-home naloxone prescriptions for patients at risk for overdose.

"Number one is audit and feedback," which means "looking at all eligible patients who weren't prescribed it, seeing which providers are not prescribing it, and providing that feedback to them," Repplinger told Medscape Medical News. This practice could also help reveal the barriers that exist to prescribing and present opportunities for provider education — the other component.

The educational component should provide some sort of evidence-based information to prove that "this saves lives, doesn't increase abuse potential, and is the right thing to do," he said.

The research was funded by the National Institute on Drug Abuse and the Emergency Medicine Foundation. Shafer and Repplinger have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2018 Scientific Assembly: Abstract 390. Presented October 3, 2018.

Follow Medscape on Twitter @Medscape and Tara Haelle @TaraHaelle

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