Increasing Number of States Require Naloxone to be Co-Prescribed with Opioids

August 15, 2019|1:22 p.m.| ASTHO Staff

This month’s Vital Signs report from CDC examines the prescribing and dispensing of naloxone by retail pharmacies. The availability of naloxone, a medication that can reverse the effects of an opioid overdose, has been identified by the U.S. Surgeon General as a key component in the public response to the opioid epidemic. The CDC report reveals that the prescribing and dispensing of naloxone has increased over the last few years while acknowledging additional room for improvement. For example, in 2018, only one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions (i.e., prescriptions for opioid dosages equal to or greater than 50 morphine milligram equivalents, or MME, per day).

The report notes that the highest county-level naloxone dispensing rates were found in states with laws that require the co-prescribing of naloxone and opioids in certain situations. Co-prescribing naloxone and opioids is a recommendation in the CDC Guideline for Prescribing Opioids for Chronic Pain and research of such requirements in states that first adopted them shows that the laws are associated with an increase in naloxone dispensing. Co-prescribing naloxone with opioid prescriptions is now required by statute or regulation in Arizona, Florida, New Mexico, Rhode Island, Vermont, Virginia, and Washington state, while laws in California and Ohio require prescribers to offer naloxone co-prescriptions in certain circumstances. Below is a brief review of state naloxone co-prescribing laws and their components.

State naloxone co-prescribing laws typically apply when certain patient risk factors are present. These risk factors may include the daily MME dosage, a history of substance abuse or overdose, a concurrent benzodiazepine prescription, and other factors. Most of the state laws require the co-prescribing or offer to co-prescribe naloxone when the daily MME dosage reaches a certain amount. Rhode Island requires a naloxone prescription when the daily opioid dosage equals or exceeds 50 MME. Ohio prescribers must offer a naloxone co-prescription when the opioid daily dosage equals or exceeds 80 MME. Arizona, California, and Vermont set the daily dosage limit at 90 MME and Virginia requires prescribers (e.g., nurse practitioners [chronic pain, acute pain], dentists, physicians [chronic pain, acute pain]) to co-prescribe naloxone when the daily opioid dosage exceeds 120 MME. Four states (California, Ohio, Rhode Island, and Virginia) require the co-prescribing or offer to co-prescribe naloxone when the patient has a history of substance abuse or overdose. These states and Vermont also include a concurrent benzodiazepine prescription as another factor for co-prescribing or offering a co-prescription of naloxone. In California, the failure by a prescriber to offer a naloxone co-prescription as required by the law is subject to a licensing board referral for sanctions.

Other states have taken different approaches to co-prescribing naloxone. In Florida, co-prescribing is required whenever a “prescription for Schedule II controlled substance for pain related to a traumatic injury with an Injury Severity Score of 9 or greater.” Washington State’s law requires a co-prescription of naloxone for high-risk patients without specifying the specific risk factors. Finally, the latest state to adopt a naloxone co-prescribing law, New Mexico, requires a naloxone co-prescription when the opioid prescription is at least a five-day supply. State health agencies have a unique opportunity to address the opioid epidemic through the establishment of naloxone co-prescribing requirements and educating policymakers on the evidence surrounding the impact of such requirements on the availability of naloxone. ASTHO will continue to monitor legislative activity on this important public health issue.