Presence of opioid safety initiatives, prescribing patterns for opioid and naloxone, and perceived barriers to prescribing naloxone: Cross-sectional survey results based on practice type, scope, and location
Authors: Kohan, MD Lynn R. , Elmofty, MD Dalia , Pena, MD Israel , Liao, MS Chuanhong 
Published: March 2021

Background and objectives: The opioid epidemic is a public health crisis in the United States (US) and is associated with devastating consequences, including opioid misuse and related overdose. In response to the opioid crisis, the US Department of Health and Human Services is advancing improved practices in pain management. Strategies to help mitigate opioid risks include physician safety programs, hospital- or practice-based initiatives, patient education, and harm reduction campaigns that include the use of naloxone. To date, little information is available regarding the use of these strategies among healthcare providers. A survey was conducted to identify the presence of opioid safety initiatives, prescribing patterns of opioids and naloxone, and perceived barriers to prescribing naloxone. The presence of these strategies was compared between different practice types (hospital-based/academic vs. private practice), practice scope (chronic pain vs. “other”), and practice location (in the US vs. outside the US) Regarding “outside the US,” the actual geographical distribution of those countries was not captured by respondents. Methods: A 13-question web-based anonymous cross-sectional survey was sent to members of the American Society of Regional Anesthesia and Pain Medicine and the Women in Pain Medicine online community via email and social media (Twitter and Facebook). Survey questions were designed to ascertain the presence of opioid safety initiatives, opioid and naloxone prescribing patterns, and perceived barriers to prescribing naloxone based on practice type (hospital-based/ academic vs. private practice), scope (chronic pain vs. “other”), and location (in the US vs. outside the US). Results: Opioid safety initiatives: The presence of physician safety initiatives was found to be statistically higher among hospital-based/academic practices. No statistical difference was found for hospital- or practice-based, patient education, or harm reduction initiatives for different practice types (hospital-based/academic vs. private practice). The presence of patient education initiatives is statistically higher for chronic pain providers versus others. No statistical difference was found for physician safety, hospital- or practice-based, or harm reduction initiatives among the different practice scopes (chronic pain vs. others). The presence of opioid safety initiatives is statistically higher in the US compared with outside the US Prescribing patterns for opioids: Hospital-based/academic practices are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, a mandatory medication treatment program, and/or a current methadone maintenance program, and those having difficulty accessing emergency medical services. Chronic pain providers are more likely to prescribe opioids to patients taking antidepressants compared with “other” providers. Other providers are more likely to prescribe opioids to patients suspected of the following: illicit or nonmedical drug use, recently released from prison or correctional facility, in opioid detoxification, in mandatory medication treatment programs, in current methadone maintenance programs, and patients having difficulty accessing emergency medical services. There is no difference in opioid prescribing patterns based on practice location. Prescribing pattern for naloxone: Chronic pain providers and providers in the US are more likely to prescribe/recommend naloxone and are more aware of a state’s medical board guidelines on naloxone prescribing. There is no statistical difference between practice types. Most providers, regardless of practice type, scope, or location, will coprescribe naloxone at a morphine milligram equivalent per day threshold of >50. Hospital-based/academic practices are more likely to prescribe naloxone to patients with opioid prescriptions and coexisting respiratory disease. Chronic pain providers are more likely to prescribe naloxone for patients with methadone prescriptions in opioid-naïve populations, coexisting respiratory, hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, and those having difficulty accessing emergency medical services. Based on practice location, providers in the US are more likely to prescribe naloxone for patients with opioid prescriptions and coexisting hepatic and/or renal dysfunction, known or suspected alcohol use, coprescribed benzodiazepine or antidepressants, recently released from a correctional facility, opioid detoxification program or mandatory abstinence program, and those having difficulty accessing emergency medical services. Perceived barriers to prescribing naloxone: We found no statistical difference regarding obstacles to prescribing naloxone based on practice type. The cost of the medication and lack of interest from patients are perceived barriers encountered by chronic pain providers versus other providers who do not have enough knowledge regarding when and how to prescribe for a patient. Based on practice location, perceived barriers for providers in the US are related to medication costs and lack of interest from patients. Conclusion: While some improvements have been achieved in the fight against the opioid epidemic, our survey results indicate that further knowledge is needed to determine the potential obstacles to implementing opioid safety initiatives, understanding prescribing practices for opioids and naloxone, and lowering the barriers to prescribing naloxone based on practice type, scope, and location.