Differences in Naloxone Prescribing by Patient Age, Ethnicity, and Clinic Location Among Patients at High-Risk of Opioid
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Department of Internal Medicine , Maine Medical Center, Portland, ME, USA; 2Tufts University School of Medicine, Boston, MA, USA; 3Department of Family Medicine, Maine Medical Center, Portland, ME, USA; 4Maine Medical Center Research Institute, Scarborough, ME, USA; 5InterMed Infectious Disease, Portland, ME, USA.
J Gen Intern Med DOI: 10.1007/s11606-019-05405-9 © Society of General Internal Medicine 2019
INTRODUCTION
Between 2016 and 2017, opioid overdose deaths increased by 12% in the USA, with one third of deaths attributed to prescription opioids.1 In response, communities and health care providers have distributed naloxone, a safe and cost-effective reversal agent for opioid intoxication, to people who inject drugs and, increasingly, other patient populations considered high-risk for opioid overdose. In March 2016, the Centers for Disease Control and Prevention (CDC) released a category A recommendation that naloxone be considered for coprescription to adults at high-risk for opioid overdose, including those with a history of overdose, history of substance use disorder, high opioid dosage (≥ 50 morphine mg equivalent/ day), or concurrent benzodiazepines.2 In a population of patients receiving care at outpatient internal medicine (IM) clinics following the release of these recommendations, we report adherence to CDC recommendations and investigate associations between patient characteristics, clinic location, and CDC criteria with naloxone prescription.
METHODS
We retrospectively collected data on adult (≥ 18 years) patients who visited any of five outpatient IM clinics (Cumberland County, ME) between April 1, 2016, and December 31, 2018, and met ≥ 1 CDC criterion for being high-risk for opioid overdose.2 We restricted substance use disorder to opioid use disorder (OUD) and history of overdose to history of opioid overdose. We abstracted data on patient demographics, clinic location, high-risk criteria, and naloxone prescription from an outpatient IM provider or upon hospital discharge from the Received July 15, 2019 Accepted September 20, 2019
electronic medical record (EMR). We excluded one patient with documented naloxone prescription before April 1, 2016. We compared the prevalence of naloxone prescription during the study interval by patient demographics, clinic location (≥ or < state median household income), and high-risk criteria. We calculated statistical significance between groups using chi-square or Fisher’s exact tests. All analyses were performed in SAS EG (version 7.15). The Maine Medical Center Institutional Review Board approved this study.
RESULTS
Over a 33-month period, 1385 adult IM clinic patients were considered high-risk for opioid overdose, and 85 (6.1%) of whom were prescribed naloxone. The prevalence of naloxone prescription was higher for younger patients [e.g., 25–34 years (14.8%) vs. 55–64 years (3.9%), p < 0.0001], patients receiving care at a clinic in a lower-income community [< state median household income (8.4%) vs. ≥ state median household income (3.7%), p = 0.0003],
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