Naloxone Co-Prescribing across a Large Health System: A Quality Improvement Project

Background: Naloxone availability and early administration is key in helping individuals survive opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of their at-risk patients had naloxone available to them. Through unpublished data, we have seen this trend hold roughly across all the subsidiaries in the Maine Health System (which includes over 30 clinics serving 1.1 million patients).

Methods: Our study first determined a baseline co-prescribing rate by querying the Maine Health EMR, generating a de-identified data set looking at the following terms: naloxone on the medication list, high MME opioid prescription on the medication list, concurrence of benzodiazepine and opioid on the medication list, concurrence of sedative/hypnotic and opioid on the medication list, diagnosis of Opioid Use Disorder, diagnosis of Substance Use Disorder, Opioid Overdose on active problem list, Opioid Overdose in the medical history. These data were stratified as well as analyzed in aggregate. After this, our team implemented many interventions across the system, including creation of enduring video materials online and creating Best Practices Advisories in the EMR, in an effort to perform Plan-Do-Study-Act cycles of process improvement.

Results: After launching the educational videos, we noticed an overall 7% increase in naloxone co-prescribing across the system, being relatively evenly spread across all sites. Following this, the Best Practice Advisory resulted in 12% improvement. The total improvement with all interventions was 21.5%.
Upon data stratification, we noted that Western Maine Health, had a 30% increase that predated our efforts (60% in individuals with OUD). After interviewing of multiple members of this system, we realized that their leadership made naloxone co-prescribing an annual goal, and they quickly mobilized individuals to offer psychoeducation, and prescribe naloxone to all patients in MOUD groups.

Conclusions: By far, the intervention that made the most difference was unifying a system using an Annual Goal and mobilizing a team around that goal. EMR changes also had a significant impact. Educational efforts produced modest effects. Even with these gains, we have not yet achieved >60% co-prescribing across all systems. Our future directions will be to engage leadership across all sites in issuing similar Annual Goals.

References: 1. Chou et al. "Management of Suspected Opioid Overdose With Naloxone in Out-of-Hospital Settings: A Systematic Review." Annals of Internal Medicine. 2017.
2. O'Donnell et al. "Trends in Deaths Involving Heroin and Synthetic Opioids Excluding Methadone, a Law Enforcement Drug Product Reports by Census Region -- United States, 2006-2015. MMWR. 2017.
3. Howell et al. "CDC Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016" MMWR, 2016.
4. Kispert et al. "Differences in Naloxone Prescribing by Patient Age, Ethnicity, and Clinic Location Among Patients at High--Risk of Opioid Overdose." J Gen Intern Med. 2020.