Background: Opioid overdose in the United States continues to rise. Naloxone is an opioid antagonist that is FDA-approved for reversing opioid overdose. Current CDC guidelines recommend prescribing naloxone to patients at high risk of opioid overdose, including patients with concurrent benzodiazepine use, a prior history of overdose, and those receiving high doses of opioids (>50 morphine milligram equivalents (MME)). While naloxone distribution programs have been shown to be effective, prescriptions for this medication remain low. For hospitalized patients at high risk of opioid overdose, an opportunity exists for naloxone to be prescribed upon discharge from the hospital.
Purpose: The goal of this project was to increase the number of patients at high risk of opioid overdose receiving naloxone prescriptions upon discharge from the hospital.
Description: Our study was a pre- and post-intervention quality improvement study of all patients on a hospital medicine service at an 895-bed urban academic medical center. The pre-intervention data showed a monthly average of 3.7 naloxone prescriptions on discharge between September 2019 and February 2020. Our intervention included educational sessions for hospitalist providers, a best practice alert in the electronic medical record (EMR) to remind hospitalists of those patients receiving high doses of opioids, and additional pharmacy support. Educational sessions were provided at two hospital medicine division meetings and included indications for naloxone and tips on prescribing and counseling. We subsequently implemented the EMR alert to fire in the discharge medication reconciliation if the patient was receiving >50 MMEs. The alert included the naloxone spray order and a consult to pharmacy for naloxone education. Pharmacy staff also prompted hospitalist providers for a prescription when other risk factors for opioid overdose were present. Hospitalist discharge nurses checked price and re-enforced education. After the education session and emails, from March 2020 to July 2020, naloxone was prescribed on average of 4.9 times per month. After the EMR alert was implemented, the post-intervention data from August 2020-October 2020 showed an average of 35.1 prescriptions per month (p=0.01). Across all hospital medicine patients, there was an 849% increase in naloxone prescriptions.
Conclusions: The vast majority of hospitalized patients at high risk of opioid overdose had not been receiving appropriate naloxone prescriptions upon discharge. Increasing the prescription of naloxone requires multi-disciplinary support and education for providers. Our intervention focused on education and improving ease of ordering and led to increased naloxone prescription to those patients who are most likely to benefit.