Abstract
This study uses Medicare Part D data to compare US national and state rates of co-prescribing of naloxone with opioids and benzodiazepines in 2016-2017.
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.
Methods
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).
Results
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).
Figure. Rates of Naloxone Co-prescription Within 7 Days Among Medicare Part D Beneficiaries Receiving Prescription Opioids, United States, 2016-2017.
MME indicates morphine milligram equivalents.
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).
Table. State Rates of Naloxone Co-prescription Within 7 Days Among Medicare Part D Beneficiaries Receiving Prescription Opioids, 2016-2017a.
| State | Maximum MME/d | Opioids and Benzodiazepines | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Any Opioid | <50 MME | 50-89 MME | ≥90 MME | Any Opioid and Benzodiazepine | Opioid and Benzodiazepine ≥300 d/y | Opioid and Benzodiazepine ≥300 d/y and ≥90 MME | ||||||||
| 2016 | 2017 | 2016 | 2017 | 2016 | 2017 | 2016 | 2017 | 2016 | 2017 | 2016 | 2017 | 2016 | 2017 | |
| Top 10 Statesb | ||||||||||||||
| Virginia | 1.2 | 33.0 | 0.1 | 9.3 | 0.5 | 28.5 | 6.3 | 141.1 | 2.5 | 76.3 | 7.8 | 225.5 | 12.1 | 298.9 |
| Vermont | 2.0 | 32.3 | NRc | 10.4 | NRc | 25.2 | 8.7 | 120.5 | 4.5 | 75.6 | 21.0 | 214.0 | 31.9 | 236.3 |
| Maryland | 4.2 | 16.9 | 0.2 | 1.9 | 1.3 | 9.4 | 20.1 | 78.4 | 8.6 | 33.4 | 32.8 | 118.2 | 43.0 | 148.1 |
| Tennessee | 3.7 | 13.5 | 0.2 | 2.5 | 1.9 | 8.6 | 14.9 | 51.5 | 5.7 | 21.5 | 10.9 | 43.8 | 17.8 | 68.5 |
| New Mexico | 7.7 | 11.8 | 1.5 | 1.7 | 5.3 | 8.3 | 34.6 | 58.8 | 13.8 | 23.4 | 46.7 | 66.2 | 65.4 | 97.9 |
| Oklahoma | 6.4 | 11.5 | 0.8 | 2.1 | 4.2 | 9.4 | 21.9 | 37.7 | 10.3 | 20.3 | 22.4 | 43.5 | 29.7 | 57.5 |
| North Carolina | 6.4 | 11.1 | 1.1 | 2.1 | 3.8 | 8.3 | 24.9 | 44.7 | 10.8 | 17.0 | 24.7 | 41.0 | 35.0 | 59.2 |
| Alaska | NRc | 9.8 | NAd | NRc | NRc | NRc | NRc | 37.2 | NRc | 20.8 | NAd | 42.3 | NAd | 47.4 |
| Arizona | 1.4 | 7.9 | 0.2 | 0.8 | 0.6 | 4.0 | 5.9 | 36.2 | 2.4 | 13.7 | 7.6 | 41.3 | 9.6 | 56.8 |
| West Virginia | 0.8 | 7.2 | NRc | 0.8 | NRc | 4.6 | 4.7 | 42.3 | 1.1 | 11.3 | 2.2 | 21.7 | 5.5 | 44.8 |
| Bottom 10 Statesb | ||||||||||||||
| South Dakota | 0.4 | 2.0 | NAd | NRc | NRc | NRc | NRc | 10.9 | NRc | 4.1 | NRc | NRc | NRc | NRc |
| Mississippi | 0.3 | 1.7 | NRc | 0.3 | NRc | 1.5 | 1.9 | 8.7 | 0.7 | 3.9 | 1.9 | 10.3 | 3.3 | 15.6 |
| Hawaii | NRc | 1.7 | NRc | NRc | NAd | NRc | NRc | 11.3 | NAd | 3.6 | NAd | NRc | NAd | NRc |
| North Dakota | 0.5 | 1.7 | NRc | NAd | NAd | NRc | NRc | 10.4 | NRc | 3.1 | NRc | NRc | NRc | NRc |
| New York | 0.6 | 1.5 | 0.1 | 0.2 | 0.3 | 1.1 | 3.5 | 8.7 | 1.4 | 3.5 | 5.3 | 12.0 | 7.7 | 16.8 |
| Illinois | 0.3 | 1.2 | NRc | 0.1 | 0.2 | 0.9 | 2.1 | 8.3 | 0.7 | 2.8 | 3.2 | 10.8 | 5.6 | 18.9 |
| Ohio | 0.7 | 1.2 | 0.2 | 0.2 | 0.5 | 1.0 | 3.3 | 6.1 | 1.2 | 2.8 | 3.1 | 8.2 | 4.8 | 13.0 |
| Louisiana | 0.9 | 1.0 | 0.1 | 0.1 | 0.5 | 0.5 | 4.7 | 5.3 | 1.9 | 1.9 | 6.0 | 5.9 | 10.3 | 10.0 |
| Iowa | 0.5 | 0.8 | NRc | NRc | NRc | 0.4 | 2.6 | 4.9 | 0.8 | 1.4 | 4.4 | 5.6 | 7.8 | 9.8 |
| Nebraska | 0.4 | 0.7 | NRc | NRc | NRc | NRc | 2.4 | 4.4 | 0.9 | 1.7 | NRc | 6.6 | NRc | NRc |
Abbreviations: MME, morphine milligram equivalents; NA, not available; NR, not reported.
Rates are per 1000 Medicare Part D beneficiaries receiving opioids in each category. Comparison of overall co-prescribing rates for “any opioid” in other states between 2016 and 2017: Washington, 3.1-6.9; Utah, 5.5-6.8; Colorado, 2.2-6.5; Wisconsin, 1.9-6.3; Wyoming, 1.7-5.6; Delaware, 1.4-5.2; Massachusetts, 4.0-5.0; Oregon, 2.1-4.8; District of Columbia, 1.1-4.7; Connecticut, 3.0-4.0; Missouri, 0.6-4.0; Nevada, 1.4-3.7; Pennsylvania, 1.0-3.2; Kentucky, 1.4-3.2; Michigan, 0.9-3.1; South Carolina, 1.1-2.9; Rhode Island, 2.4-2.9; Florida, 0.7-2.8; New Hampshire, 1.9-2.5; Kansas, 0.8-2.5; Alabama, 0.9-2.5; Montana, 0.8-2.5; New Jersey, 0.4-2.4; Maine, 1.0-2.4; California, 1.4-2.4; Minnesota, 0.8-2.3; Texas, 0.9-2.2; Idaho, 0.6-2.2; Arkansas, 0.3-2.1; Indiana, 0.6-2.1; Georgia, 0.8-2.1.
States are ordered based on descending rates of overall co-prescribing.
Data have been suppressed based on privacy requirements.
No data for the measure.
Discussion
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.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
References
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