Atlanta—The good news from a CDC report is that naloxone dispensing from retail pharmacies increased from 2012 to 2018, with substantial increases in recent years.

There also was bad news, however. An article in the Morbidity & Mortality Weekly Report points out, “Despite increases, in 2018, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions..” Furthermore, public health officials note that the lowest rates of naloxone dispensing were observed in the most rural counties.

The issue is a critical one, according to the CDC, because, In 2017, 47,600 persons died from drug overdoses involving opioids. Naloxone temporarily reverses the effects of opioids and can help prevent overdose deaths.

“Additional efforts are needed to improve naloxone access at the local level, including prescribing and pharmacy dispensing. Distribution of naloxone is a critical component of the public health response to the opioid overdose epidemic,” write the authors from the CDC’s Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, and colleagues.

The report states that naloxone dispensing doubled from 2017 to 2018, but that dispensing rates remained low. At the same time, high-dose opioid dispensing declined by 21%. The CDC authors assert, “Missed opportunities remain to implement strategies to provide naloxone to patients at risk for overdose. The release of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain has been associated with accelerated declines in high-dose opioid dispensing. Additional efforts to implement the guideline recommendations have the potential to improve naloxone dispensing.”

The authors explain that, in 2018, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions, although receipt of a high-dose opioid prescription is a known risk factor for overdose. The study points out, “If each provider had considered offering naloxone to every patient receiving a high-dose opioid prescription, as recommended in the CDC guideline, nearly 9 million naloxone prescriptions could have been dispensed, approximately 16 times the 557,000 recorded in 2018.”

In addition, according to the MMWR article, “in one in 12 counties, high-dose opioids were dispensed, but naloxone was not dispensed from a pharmacy. Further, there was a twenty-fivefold variation in naloxone dispensing across counties, with rural counties and the Midwest experiencing the lowest rates despite laws permitting pharmacy-based naloxone dispensing in all 50 states and the District of Columbia.”

The CDC emphasizes that naloxone access laws that grant direct authority to pharmacists to dispense naloxone have been associated with reduced fatal opioid overdoses.

Which areas had the highest rates of pharmacy-based naloxone dispensing? The authors list the following:
• Counties with the greatest need for overdose reversal, (e.g., those with high rates of drug overdose death and high-dose opioid dispensing);
• In states hit hardest by opioid overdose mortality, such as Florida and Massachusetts; and
• In states that have implemented requirements for naloxone coprescribing, such as Arizona and Virginia.

The article notes that more states have recently implemented laws requiring coprescription but not enough time has passed to evaluate them.

The greatest concern is with pharmacy naloxone dispensing rates is in less-populated areas, according to the authors, who write, “Compared with metropolitan counties, rural counties had a higher likelihood of having low rates of naloxone dispensing, even when controlling for other relevant factors. This is concerning given slower EMS response times and underuse of naloxone by EMS in rural areas relative to the overdose prevalence, which are potentially attributable to resource, certification, and practice constraints. Harm-reduction programs are more limited in rural areas, and a smaller proportion of rural programs distribute naloxone. Thus, pharmacy naloxone dispensing holds great promise for positive impact in rural communities.”

The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present, including history of overdose or substance-use disorder, opioid dosages of 50 morphine-milligram equivalents per day or greater (high-dose), and concurrent use of benzodiazepines.

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