Vital Signs

Pharmacy-Based Naloxone Dispensing — United States, 2012–2018

Gery P. Guy, Jr., PhD; Tamara M. Haegerich, PhD; Mary E. Evans, MD; Jan L. Losby, PhD; Randall Young, MA; Christopher M. Jones, PharmD, DrPH

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(31):679-686. 

In This Article

Abstract and Introduction

Abstract

Background: The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages ≥50 morphine milligram equivalents per day [high-dose], and concurrent use of benzodiazepines). In light of the high numbers of drug overdose deaths involving opioids, 36% of which in 2017 involved prescription opioids, improving access to naloxone is a public health priority. CDC examined trends and characteristics of naloxone dispensing from retail pharmacies at the national and county levels in the United States.

Methods: CDC analyzed 2012–2018 retail pharmacy data from IQVIA, a health care, data science, and technology company, to assess U.S. naloxone dispensing by U.S. Census region, urban/rural status, prescriber specialty, and recipient characteristics, including age group, sex, out-of-pocket costs, and method of payment. Factors associated with naloxone dispensing at the county level also were examined.

Results: The number of naloxone prescriptions dispensed from retail pharmacies increased substantially from 2012 to 2018, including a 106% increase from 2017 to 2018 alone. Nationally, in 2018, one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. Substantial regional variation in naloxone dispensing was found, including a twenty-fivefold variation across counties, with lowest rates in the most rural counties. A wide variation was also noted by prescriber specialty. Compared with naloxone prescriptions paid for with Medicaid and commercial insurance, a larger percentage of prescriptions paid for with Medicare required out-of-pocket costs.

Conclusion: Despite substantial increases in naloxone dispensing, the rate of naloxone prescriptions dispensed per high-dose opioid prescription remains low, and overall naloxone dispensing varies substantially across the country. Naloxone distribution is an important component of the public health response to the opioid overdose epidemic. Health care providers can prescribe or dispense naloxone when overdose risk factors are present and counsel patients on how to use it. Efforts to improve naloxone access and distribution work most effectively with efforts to improve opioid prescribing, implement other harm-reduction strategies, promote linkage to medications for opioid use disorder treatment, and enhance public health and public safety partnerships.

Introduction

Among the 70,237 drug overdose deaths in the United States in 2017 (the last year for which complete data are available), a total of 47,600 (67.8%) involved opioids.[1] Millions of Americans are at increased risk for an opioid overdose, including persons who use illicit opioids, those who use or misuse prescription opioids, and those with an opioid use disorder.[2] A population particularly at risk includes persons who use illicit drugs (e.g., cocaine and methamphetamine) that might be mixed with illicit opioids.[3] The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages ≥50 morphine milligram equivalents [MME] per day [high-dose], and concurrent use of benzodiazepines).[4] Given that approximately two thirds of overdose deaths involved opioids, 36% of which in 2017 were prescription opioids,[1] the distribution of naloxone to reverse an overdose is an important element of the public health response to the opioid overdose epidemic.[5]

For decades, emergency medical service (EMS) providers, first responders, and emergency department clinicians have administered naloxone in cases of suspected drug overdose, and community-based organizations have offered naloxone through education and distribution programs. Recent efforts have focused on expanding naloxone access through clinician prescribing and pharmacy dispensing. All 50 states and the District of Columbia have enacted laws permitting pharmacy-based naloxone dispensing.[6] Laws allowing providers to prescribe naloxone to any persons in a position to assist another with an overdose (i.e., third-party prescriptions) and standing orders for pharmacists to dispense naloxone have been associated with increases in naloxone dispensing from retail pharmacies.[7] Several states have mandated that clinicians coprescribe naloxone when overdose risk factors (e.g., high opioid dosages) are present, a recommendation for consideration in the CDC Guideline for Prescribing Opioids for Chronic Pain;[4] such laws have been associated with substantial increases in naloxone dispensing.[8] Many of these states have only recently implemented these laws; thus, sufficient time has not passed to examine their full impact at the state or county level.

Recent analyses examining the extent and characteristics of pharmacy-based naloxone dispensing are lacking. Also unknown is the extent to which naloxone dispensing varies by county and by other factors (e.g., prescriber specialty and patient insurance coverage). Understanding variation could help identify the need for tailored approaches to improve prescribing and dispensing, similar to those that have been indicated for opioid prescribing.[9] To address this gap and to inform future overdose prevention and response efforts, CDC examined trends in, and characteristics of, naloxone dispensing from retail pharmacies at the national and county levels in the United States.

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