Background: Driven by the current opioid epidemic, drug overdose has become the leading cause of unintentional death nationwide. Efforts are underway to decrease unnecessary opioid prescribing. Hospitalists care for many patients with preexisting opioid prescriptions or appropriately prescribed new opioids at discharge. Though naloxone decreases the morbidity and mortality associated with opioid overdose, most patients prescribed opioids do not receive a prescription for naloxone at discharge.
Purpose: Increase the rates of naloxone prescription at discharge among all medicine patients at risk of opioid overdose including patients with new opioid prescriptions, existing opioid prescriptions, history of opioid use disorder, and history of any overdose in an urban, safety net hospital.
Description: In response to an institution-wide quality improvement incentive program, a team of six internal medicine residents, a faculty hospitalist, and a clinical pharmacist collaborated with nursing, pharmacy and inpatient teams to increase safety around opioid use at discharge. Baseline data from our internal medicine resident-led inpatient services demonstrated that only 8.3% of patients who filled an opioid prescription at our discharge pharmacy were co-prescribed naloxone. In order to increase this rate, we first aligned with hospital leadership to secure funding for naloxone for the minority of patients who did not have insurance coverage for this prescription. We then developed an educational campaign for housestaff, nursing, hospitalists and pharmacists about identifying patients at risk of opioid overdose and indications for prescribing naloxone. Educational interventions included monthly addiction medicine didactics, widely disseminated educational material, development of decision support tools in our electronic health record, and one-on-one coaching with nursing and clinical pharmacists. We also provided biweekly updates to housestaff, pharmacists and hospitalists on rates of opioid-naloxone co-prescribing stratified by medical team to foster a sense of competition. Residents will receive a small financial incentive if a pre-specified target of 25% of patients discharged with an opioid prescription are co-prescribed naloxone. One month after the initiation of our project, the rate of naloxone co-prescriptions increased from 8.3% to 46.6%.
Conclusions: Our resident led multidisciplinary, multifaceted approach effectively increased naloxone prescribing to at-risk groups one month after implementation. Our group continues to implement PDSA cycles to evaluate barriers to prescribing. Future efforts will focus on continued education toward patients and families, working with nursing to better identify patients at risk for opioid overdose and expanding the initiative to surgical services within the hospital. In addition, we hope to examine whether this intervention will lead to changes in opioid prescribing at discharge and how to sustainably continue to prescribe naloxone at discharge for at-risk patients.