Kaiser Permanente study identifies barriers to prescribing potentially life-saving medication

A variety of factors including questions about risk and reluctance to offend patients limits clinician willingness to prescribe a potentially life-saving medication that counteracts the effects of an opioid overdose, according to a Kaiser Permanente Colorado study published today in the Journal of General Internal Medicine.

The number of fatal overdoses from opioid medications has quadrupled in the U.S. since 1999. According to the Centers for Disease Control and Prevention (CDC), each day 44 people die of prescription painkiller overdoses. In the event of an overdose, opioids depress respiration until breathing stops. The drug naloxone reverses these effects on the body and can be life-saving.

The medication is typically prescribed to patients taking opioid painkillers, and is meant to be administered by family members or other bystanders in the event of an overdose. It is widely viewed as promising tool to prevent deaths. Thirty states, including Colorado, and Washington, D.C., have signed legislation allowing clinicians to prescribe naloxone or have pilot programs in place to distribute the medication.

Researchers from Kaiser Permanente, Denver Health Medical Center and University of Colorado School of Medicine conducted 10 focus groups with 56 clinicians from August 2013 - August 2014. These focus groups obtained feedback on attitudes about prescribing naloxone to patients also taking opioids prescribed for pain at internal medicine, family medicine and HIV clinics. Key findings include:

• Clinicians commonly expressed beliefs that naloxone could effectively prevent overdose deaths. Prescribing the drug may increase patient understanding of the risks associated with opioid use.

• Only three of the 37 clinicians with prescribing authority had prescribed naloxone.

• There were logistical challenges, such as time restraints within clinical appointments, to widespread naloxone prescribing in busy primary care practices.

• Clinicians were hesitant to prescribe naloxone. They did not want to offend patients by talking to them about their risk of overdose.

• Clinicians wanted to be certain that the bystanders who would actually deliver naloxone receive proper and confidential training, and are able to recognize the signs of an overdose.

• Clinicians expressed concerns about possible adverse effects of the drug in widespread use. Focus group participants wanted evidence that having naloxone available does not lead to riskier use of opioids.

"Given the substantial increase in fatal overdoses from pharmaceutical opioids in the U.S. in recent years, expanding access to naloxone is a promising option to prevent future deaths," said lead study author Ingrid Binswanger, MD, MPH, senior investigator for Kaiser Permanente Colorado's Institute for Health Research. "However, research shows there are gaps in knowledge about how to use naloxone in routine clinical practice. It's evident that more education is needed to support clinicians as states begin legislating wider access of naloxone for bystanders of overdoses."

Further research is also needed to address the questions raised by clinicians in the study focus groups regarding how increased naloxone prescribing impacts patient satisfaction, opioid use and patient safety, according to Dr. Binswanger.

Through its highly coordinated integrated care delivery system, Kaiser Permanente is committed to furthering understanding of opioid use and preventing prescription drug abuse. In 2013, a Kaiser Permanente Institute for Health Research study found that chronic use of prescription painkillers continues following bariatric surgery. In Colorado, the health plan is a member of the Colorado Consortium for Prescription Drug Abuse Prevention, launched by Governor John Hickenlooper in 2013 to reduce the abuse and misuse of prescription drugs in the state.