As opioid overdose deaths soar during the COVID-19 pandemic, a Michigan Medicine study found that the vast majority of patients treated for opioid overdoses in United States emergency departments don’t receive two potentially lifesaving medications before they leave the hospital or in the weeks soon after.
Analysis of data from nearly 149,000 emergency department visits for opioid overdose before and during the pandemic reveal that only 7.4% of patients received a prescription for naloxone, an overdose rescue drug often available under the name Narcan, within 30 days. The prescription rate for buprenorphine, a medication to treat opioid addiction, was just 8.5%.
The results, published in the Annals of Emergency Medicine, come just as the Centers for Disease Control and Prevention announced U.S. drug overdoses exceeded 100,000 for the first time in a 12-month period that ended in April 2021, a 28.5% increase from the same period one year earlier. The new study analyzes prescriptions written after emergency department visits for overdose between August 2019 and April 2021.
The strikingly low numbers of naloxone and buprenorphine prescriptions highlight many missed opportunities for equipping patients with rescue medicines to use in case they or others overdose in the future, and starting appropriate patients on addiction treatment in both the emergency department and follow-up care, says Kao-Ping Chua, M.D., Ph.D., lead author of the study and assistant professor of pediatrics at Michigan Medicine.
“In light of the record levels of opioid overdose deaths, the low levels of naloxone and buprenorphine prescribing are simply unacceptable,” Chua said. “Clinicians are missing critical opportunities to save lives both in the emergency department and during follow-up after overdose visits.”
Naloxone can be administered nasally or through an injection, similar to epinephrine used for people with severe allergies. It’s designed to restore normal breathing during an overdose and is increasingly available for free from pharmacies and other locations. Buprenorphine is also an opioid, but it is designed to block the action of other opioid drugs, including prescription medications, heroin and fentanyl. The medication helps people reduce or eliminate their dependence on using opioids, without causing a high on its own.
The power of these medications to help people avoid future overdoses and get help for addiction is what drove the researchers to study prescriptions filled by people treated for opioid overdoses. They also looked at patients treated for severe allergic reactions – anaphylaxis – in the same emergency departments over the same time period. Nearly half of those patients received prescriptions for an emergency epinephrine device, such as an Epipen, within 30 days of their visit.
“The same standard we use in caring for patients after anaphylaxis and preparing them with a potentially life-saving prescription should also be applied to patients after an opioid overdose,” said Keith Kocher, M.D., M.P.H., senior author of the paper and associate professor of emergency medicine at Michigan Medicine. “There are several points of intervention along a path to reducing potential harm after an overdose. The emergency department has a role to play, as do providers in the outpatient setting. These may not always be the same solutions in every setting or community, but the bottom line is that we need to do better.”
The risk that patients who survive an opioid overdose will go on to die from another overdose is high. In a 2019 study, researchers found 1.1% of patients treated for opioid overdose died within one month and 5.5% died within one year.
Both Kocher and Chua recommend that, at a minimum, emergency physicians should prescribe naloxone to patients who overdose, and health systems should encourage that prescribing. Chua notes, there is still a stigma surrounding prescribing the overdose reversal agent.
“There are some clinicians who think that prescribing naloxone encourages patients to engage in risky behaviors, increasing their risk of overdose again,” he said. “But there’s not a lot of evidence that this occurs.”
As for buprenorphine, emergency departments have not traditionally been seen as the place to start addiction treatment, yet we know that ER visits are being used as “teachable moments” to try and start patients on many other kinds of treatment and lifestyle changes, Kocher says.
“We hope these statistics cut through the noise because we worry about people having this adverse experience in the weeks and months following an overdose,” he said.
Physicians looking to prescribe buprenorphine to patients experience additional hurdles. They have to apply for a waiver through the U.S. Drug Enforcement Agency and still can only prescribe the drug to 30 patients a year without having to meet additional requirements. But this past spring, other hurdles were erased, which should enable more physicians to start patients on a medication that could change their lives, Chua says.
“Congress needs to eliminate the waiver requirement for buprenorphine altogether,” he said. “We shouldn’t need a waiver to prescribe buprenorphine when we don’t need a waiver to prescribe opioids.”
Kocher and his colleagues in the Michigan Emergency Department Improvement Collaborative have worked for several years to increase the number of Michigan emergency physicians and ER teams that can provide naloxone for free to at-risk patients, including overdose survivors, and start patients on buprenorphine. In partnership with the Michigan Opioid Prescribing Engagement Network, they’ve created guides for ERs to help them start and maintain programs to encourage prescribing both medications, and have held training sessions in person and online to help physicians prepare to prescribe buprenorphine including meeting federal requirements.
They’ve also provided thousands of naloxone kits for ERs to provide for free and have created lists of pharmacies that have “standing orders” for naloxone in many Michigan counties, which allow patients to access the drug without a prescription from a specific physician.