Why is naloxone prescription not more common in emergency departments? A survey of physician practices and attitudes

David Nykin; Campbell Belisle Haley; Soheil Saadat; Tiffany Luu; Preet Kaur Sahota; Bharath Chakravarthy

doi:10.5055/jom.2023.0794

Authors

David Nykin, MD
Campbell Belisle Haley, MD https://orcid.org/0000-0002-1903-2788
Soheil Saadat, MD, MPH, PhD
Tiffany Luu, BS
Preet Kaur Sahota, MS
Bharath Chakravarthy, MD, MPH

DOI:

https://doi.org/10.5055/jom.2023.0794

Keywords:

naloxone, opioid, emergency physician, emergency department, prescriptions

Abstract

Objective: Emergency physicians (EPs) have a singular opportunity to prescribe naloxone and decrease fatal overdoses in opioid users. We surveyed EPs patterns of naloxone prescription and identified barriers to prescribing naloxone.

Design: Surveys were conducted at an emergency medicine conference from 2018 to 2019. We used a Likert scale for all questions and a chi-square or chi-square for trend tests to determine statistical significance.

Setting: Emergency medicine conferences and emergency departments.

Participants: Forty-one EPs were surveyed.

Intervention: Oral survey.

Main outcome measures: Prevalence of naloxone prescription and EP attitude toward naloxone.

Results: 65.0 percent of residents and 33.3 percent of attending physicians had never prescribed naloxone to patients. 90.2 percent believed ED naloxone prescription is safe, 82.9 percent did not refrain from prescribing due to ethical concerns, and 73.2 percent believed it is not a waste of resources.

Conclusions: Many resident physicians had never prescribed naloxone despite agreeing it was safe, ethical, and a productive use of resources. The time needed to counsel patients on naloxone use was a barrier to prescription, and various interventions are needed to make this practice more common.

Author Biographies

David Nykin, MD

Attending Physician, Department of Emergency Medicine, University of California, Irvine School of Medicine, Orange, California

Campbell Belisle Haley, MD

Resident Physician, Department of Emergency Medicine, University of California, Irvine School of Medicine, Orange, California

Soheil Saadat, MD, MPH, PhD

Attending Physician, Department of Emergency Medicine, University of California, Irvine School of Medicine, Orange, California

Tiffany Luu, BS

Medical Student, University of California, Irvine School of Medicine, Orange, California

Preet Kaur Sahota, MS

Medical Student, Arizona College of Osteopathic Medicine-Midwestern University, Glendale, Arizona

Bharath Chakravarthy, MD, MPH

Attending Physician, Department of Emergency Medicine, University of California, Irvine School of Medicine, Orange, California

References

Vital Signs: Drug overdose deaths, by selected sociodemographic and social determinants of health characteristics—25 states and the District of Columbia. 2019-2020. Available at https://www.cdc.gov/mmwr/volumes/71/wr/mm7129e2.htm?s_cid=mm7129e2_w. Accessed July 22, 2022. DOI: https://doi.org/10.15585/mmwr.mm7129e2

National Institute on Drug Abuse: Opioid overdose crisis. 2021. Available at https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis. Accessed May 26, 2021.

Smart R, Pardo B, Davis CS: Systematic review of the emerging literature on the effectiveness of naloxone access laws in the United States. Addiction. 2021; 116(1): 6-17. DOI: 10.1111/add.15163. DOI: https://doi.org/10.1111/add.15163

Rees DI, Sabia JJ, Argys LM, et al.: With a little help from my friends: The effects of good Samaritan and naloxone access laws on opioid-related deaths. J Law Econ. 2019; 62(1): 1-27. DOI: https://doi.org/10.1086/700703

Food and Drug Administration: FDA approves first over-the-counter naloxone nasal spray. US Food and Drug Administration. 2023. Available at https://www.fda.gov/newsevents/press-announcements/fda-approves-first-over-counternaloxone-nasal-spray. Accessed June 2, 2023.

Briesacher BA, Gurwitz JH, Soumerai SB: Patients at-risk for cost-related medication nonadherence: A review of the literature. J Gen Intern Med. 2007; 22: 864-871. DOI: 10.1007/s11606-007-0180-x. DOI: https://doi.org/10.1007/s11606-007-0180-x

Fareed A, Eilender P, Ketchen B, et al.: Factors affecting noncompliance with buprenorphine maintenance treatment. J Addict Med. 2014; 8(5): 345-350. DOI: 10.1097/ADM.0000000000000057. DOI: https://doi.org/10.1097/ADM.0000000000000057

Chua KP, Dahlem CHY, Nguyen TD, et al.: Naloxone and buprenorphine prescribing following US emergency department visits for suspected opioid overdose: August 2019 to April 2021. Ann Emerg Med. 2022; 79(3): 225-236. DOI: 10.1016/j.annemergmed.2021.10.005. DOI: https://doi.org/10.1016/j.annemergmed.2021.10.005

Penm J, MacKinnon NJ, Lyons MS, et al.: Combatting opioid overdoses in Ohio: Emergency department physicians' prescribing patterns and perceptions of naloxone. J Gen Int Med. 2018; 33: 608-609. DOI: 10.1007/s11606-018-4353-6. DOI: https://doi.org/10.1007/s11606-018-4353-6

McClellan C, Lambdin BH, Ali MM, et al.: Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018; 86: 90-95. DOI: 10.1016/j.addbeh.2018.03.014. DOI: https://doi.org/10.1016/j.addbeh.2018.03.014

Kilaru AS, Liu M, Gupta R, et al.: Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal. Am J Emerg Med. 2021; 47: 154-157. DOI: 10.1016/j.ajem.2021.03.056. DOI: https://doi.org/10.1016/j.ajem.2021.03.056

Drainoni M-L, Koppelman EA, Feldman JA, et al.: Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment. BMC Res Notes. 2016; 9. DOI: 10.1186/s13104-016-2268-z. DOI: https://doi.org/10.1186/s13104-016-2268-z

Coffin PO, Sullivan SD: Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Internal Med. 2013; 158(1): 1-9. DOI: https://doi.org/10.7326/0003-4819-158-1-201301010-00003

American College of Emergency Physicians: Naloxone access and utilization for suspected opioid overdoses. 2016. Available at https://www.acep.org/globalassets/new-pdfs/policystatements/naloxone-access-and-utilization-for-suspected-opioid-overdoses.pdf. Accessed May 26, 2021.

The Pew Charitable Trusts: Expanded access to naloxone can curb opioid overdose deaths. 2020. Available at https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2020/10/expanded-access-to-naloxone-can-curb-opioid-overdosedeaths. Accessed May 26, 2021.

Gonzalez AM, Arlandson ME, Patel A, et al.: Predictive factors associated with naloxone prescription among pregnant people admitted for the management of opioid use disorder. Am J Perinatol. 2022. DOI: 10.1055/a-1975-4534. DOI: https://doi.org/10.1055/a-1975-4534

Holland TJ, Penm J, Dinh M, et al.: Emergency department physicians' and pharmacists' perspectives on take-home naloxone. Drug Alcohol Rev. 2019; 38(2): 169-176. DOI: 10.1111/dar.12894. DOI: https://doi.org/10.1111/dar.12894

American Psychological Association: Substance use during the pandemic. 2021. Available at https://www.apa.org/monitor/2021/03/substance-use-pandemic. Accessed May 6, 2021.