A new prescribing alert helps physicians quickly understand how and why they should offer a naloxone prescription to a patient at high risk for an opioid overdose.
The alert contains key facts about the patient’s history, such as previous overdoses and whether a benzodiazepine has also been prescribed. The alert has led to a dramatic increase in naloxone prescribing, which was described in a recent article in Anesthesia & Analgesia.
“With this alert, we really wanted to reduce the alert-fatigue issue, and also to make it as specific as possible in terms of why a certain patient should have the prescription,” said Scott Nelson, Pharm.D., an associate professor of biomedical informatics and a clinical director for the Vanderbilt University Medical Center information technology division, known as HealthIT. Nelson served as lead author on the paper.
The approach worked. In 2019, the baseline average prescribing rate for naloxone at Vanderbilt was 0.28 prescriptions per 100 opioid prescriptions written. After the medical center implemented the alert, naloxone prescribing rates increased to 4.51 per 100 opioid prescriptions.
Persistently Huge Problem
According to the CDC, an estimated 107,622 people died from drug overdoses in the United States in 2021, nearly 15 percent more than the previous year. If overdoses were reported separately from other deaths by unintentional injury, it would rank higher than diabetes, at No. 7 with just over 100,000 annual deaths.
The Surgeon General has long recommended writing prescriptions for the opioid reversal agent naloxone as a safety measure for patients at high risk of an opioid overdose, but prescribing rates for naloxone have remained stubbornly low.
“With this alert, we really wanted to reduce the alert-fatigue issue, and also to make it as specific as possible in terms of why a certain patient should have the prescription.”
Helping to Overcome Hurdles
“Doctors may have a number of reasons for not prescribing naloxone to patients who should have it available,” said study co-author David Marcovitz, M.D., director of the Division of Addiction Psychiatry at Vanderbilt.
“Beyond the fact that it’s one more thing they’re supposed to remember to do, they may self-censor because they think that that the patient who’s being prescribed an opioid will consider it stigmatizing,” Marcovitz said.
For example, doctors may under-prescribe naloxone in older patients, who the physicians think may be offended to be offered an opioid-reversal agent. They also routinely underprescribe naloxone for children under age 18, who are at risk for unintentional respiratory depressions as well as for developing an opioid use disorder, the authors noted.
Improving on Existing Alerts
While previous naloxone reminder alerts have been developed, the way that Vanderbilt researchers approached the alert’s development and implementation involved important differences.
“For one thing, the other centers that had developed similar alerts were only directing them to prescribers in the emergency department,” Nelson said. “We are taking this across all departments – outpatient, inpatient, discharges, the emergency department everywhere.”
In addition, the Vanderbilt alert offers more useful information to the prescriber than earlier ones, he added.
“Some earlier alerts told a clinician, ‘Your patient is at risk of overdose. Prescribe naloxone.’ But they didn’t provide context,” Nelson said. “We wanted to show why the specific patient was at risk, although doing that was a little tricky technically.”
The alert notifies the doctor about the reasons behind the patient’s need for naloxone. These reasons may include having a history of overdose or opioid use , as well as the presence of other opioids or benzodiazepines on their list of current medications. The alert also gives them options for prescribing the intranasal or injectable naloxone.
The alert is triggered when a prescription is written for a different drug, usually an opioid. Upon approving the initial prescription, the doctor is automatically alerted to offer a naloxone prescription too. The background information that the alert provides can serve as the basis for a conversation with a patient that can be more substantive, and therefore somewhat easier than it might be without all the facts, the authors explained.
Benefits Ripple Out
The authors found that more than half of the patients who received a naloxone prescription filled it, which Nelson explains is below the roughly 70 to 80 percent fill rate for prescriptions overall, but it is higher than reported in previous naloxone studies, which had fill rates of between 23 and 33 percent.
In several instances, patients with a naloxone prescription even used the drug to save another person.
“Patients asked for refills because they had used their naloxone on others in their communities or households,” the authors wrote. “One patient revived her boyfriend from an overdose.”