Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project

Abstract

BACKGROUND: Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing. METHODS: We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing. RESULTS:The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52). CONCLUSIONS: A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build. (Anesth Analg 2022;135:26-34) KEY POINTS• Question: Does identifying patients at risk for opioid overdose using an alert in the electronic health record increase naloxone prescribing? • Findings: Compared to baseline, naloxone coprescribing rates increased from 0.28 (95% confidence interval [CI], 0.24-0.31) to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions after alert implementation, increasing the odds of naloxone coprescribing by approximately 28 times those during the baseline period (95% CI, 15-52). • Meaning: A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build. GLOSSARYCDC = Centers for Disease Control and Prevention; CDS = clinical decision support; CI = confidence interval; COVID-19 = coronavirus disease 2019; EHR = electronic health record; IRB = institutional review board; MEDD = morphine equivalent daily dose; OB/GYN = obstetrics and

Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

“…Currently, ED providers must identify, diagnose, and treat patients with OUD, while simultaneously caring for multiple sick patients in a highly chaotic, high‐volume setting with frequent interruptions and competing priorities. Clinical alerts for patients who have a current prescription for opioids can prompt an automated suggestion to prescribe naloxone 25 . Providers can utilize specific order sets for caring for patients with a primary or secondary chief complaint related to substance use disorder, similar to what is used for chest pain and shortness of breath, with clinical practice guidelines embedded, allowing for health care providers to easily access evidence‐based recommendations for treatment both inside and outside of the ED 26 .…”

“…Clinical alerts for patients who have a current prescription for opioids can prompt an automated suggestion to prescribe naloxone. 25 Providers can utilize specific order sets for caring for patients with a primary or secondary chief complaint related to substance use disorder, similar to what is used for chest pain and shortness of breath, with clinical practice guidelines embedded, allowing for health care providers to easily access evidence-based recommendations for treatment both inside and outside of the ED. 26 Care pathways for treatment after the patient has been stabilized and discharged from the ED can also be utilized to ensure equitable access to care and automatically alert the care team to a patient who will need emergent follow-up, provide feedback to the primary care provider who is caring for the patient long term, and allow for real-time monitoring of patient outcomes.…”

Implementation of a Naloxone Best Practice Advisory Into an Electronic Health Record

“…Our study found greater increases in prescription volume and fill rates than previously reported. 10,11 To our knowledge, this is the first study to assess statewide changes in number of patients with naloxone dispenses after implementation of a best practice alert at a single health care system. The statewide increase is striking, and although we are unable to establish a causal relationship, the timing of the increase in dispenses coincides with implementation of the BPA at Nebraska Medicine.…”

The Opioid Crisis, Centers for Disease Control Opioid Guideline, and Naloxone Coprescription for Patients at Risk for Opioid Overdose

“…The study by Nelson et al 3 noted that employment of the EHR alert system, in patients at high risk for opioid overdose, resulted in an increase from 0.28 (5% CI, 0.24–0.31) naloxone coprescription per 100 opioid prescriptions to 4.51 (95% CI, 4.33–4.68) per 100 opioid prescriptions. The departments that prescribed naloxone the most include Behavioral Health, Emergency Department, Interventional Pain Medicine, Neurosurgery, Obstetrics and Gynecology, Pediatrics, and Trauma/Burn.…”

“…Initiatives are also needed at the hospital and clinical levels. Nelson et al 3 report a practical and effective effort that leverages the EHR to increase naloxone coprescribing when indicated. In the meantime, other hospitals should consider implementing similar initiatives.…”