TRANSCRIPT of August 6, 2019, CDC Vital Signs: Naloxone

OPERATOR: Welcome, and thank you for standing by.  All participants win in listen-only mode until the question-and-answer session.  At that time, please press star-one.  Please unmute your phone and record your name at the prompt.  Today’s conference is being recorded.  If you have any objections, you may disconnect at this time.  I would now like to turn the call over to your host, Kathy Harben, you may begin.

MODERATOR: Thank you, Malinda, and thank you all for joining us today for the release of a new CDC Vital Signs, which covers trends in pharmacy-based dispensing of naloxone. We’re joined today by CDCs Principal Deputy Director, Dr. Anne Schuchat.  She will share key findings from the Vital Signs report. During the Q&A portion we’ll have Dr. Gery Guy, an economist and lead author of the study, to answer your questions. I’ll now turn the call over to Dr. Anne Schuchat.

DR. ANNE SCHUCHAT: Good afternoon, and thank you for joining us today. Each month with our Vital Signs report, we focus on the latest data about one of the critical health issues facing our nation and what can be done in response to the issue. Today, we are talking about pharmacy dispensing of naloxone as a life-saving measure for overdoses. Naloxone is a medication that can reverse the effects of an opioid overdose.

Emergency medical service providers and first responders have used naloxone for decades, and over the past two decades, community-based programs have distributed naloxone for overdose reversal.

The increase in opioid-related overdoses has led to recent efforts, further expanding access to naloxone through pharmacies based on what we call “co-prescribing.” To call attention to the importance of co-prescribing naloxone, last year the Surgeon General issued an advisory to raise awareness among providers and the public about naloxone, and last fall the Depart of Health and Human Services issued a guide for healthcare providers on naloxone prescribing.

Today’s Vital Signs study examines naloxone prescribing and dispensing from pharmacies at the national and county levels. Our report has good news and bad news related to both opioid prescribing and co-prescribing of naloxone. We are making progress in reducing high-dose opioid prescribing – but there is still too much. And we are seeing significant increases in pharmacy prescriptions for naloxone, but there is much room for improvement.

Missed opportunities remain to implement strategies at the local level that provide naloxone for patients at risk for overdose. Pharmacists and other healthcare providers play a critical role in ensuring patients receive naloxone. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends that healthcare providers consider prescribing or dispensing naloxone to patients at risk for overdose. These risk factors include taking high daily dosages of prescription opioids, using benzodiazepines concurrently with opioids, and having a history of substance use disorder.

In addition, because of the increasing availability of highly potent opioids like illegally made fentanyl in the illicit drug supply in the U.S, the HHS guide on naloxone prescribing also recommended that naloxone be considered for people misusing prescription opioids, using heroin, or using other illicit drugs like cocaine or methamphetamine that might be contaminated with fentanyl. In 2017, nearly 48,000 or 68% of all us drug overdose deaths involved opioids. A critical component of reducing drug overdose deaths is increasing the availability and targeted distribution of naloxone.

First, let me summarize what we saw with high dose prescribing – which we defined as >50 morphine milligram equivalents. This report is based on IGVIA data representing 92% of retail pharmacies in the United States. From 2017 to 2018, we saw significant improvement in high dose opioid prescribing – a 21% drop from 48 million to 38 million high-dose prescriptions. This is progress, but we think more is possible.

Next, I’ll go into detail about naloxone prescriptions, which we are trying to expand.

The number of prescriptions for naloxone has markedly increased since 2012, and prescriptions doubled from 2017 to 2018 alone – going from about 270,000 to 556,000 naloxone prescriptions each year. Despite this progress, the number of naloxone prescriptions dispensed per high-dose opioid prescription remains low and varies substantially across the country. High-dose opioid prescriptions are a risk factor for overdose. Consider these statistics from 2018:

• • Only one naloxone prescription was dispensed for every 70 high-dose opioid prescriptions.
  • Rural counties were nearly 3 times more likely to be in the low-dispensing group than were metropolitan counties.
  • Pharmacies in 1 out of every 12 counties dispensed high-dose opioids but did not dispense naloxone.
  • If each person with a high-dose opioid prescription were offered naloxone, nearly 9 million prescriptions for naloxone could have been dispensed in 2018.

As you might expect, the highest county-level naloxone dispensing rates were concentrated in some of the states hit hardest by opioid overdose deaths, such as Florida, Massachusetts, North Carolina, Pennsylvania, and Tennessee. High rates of naloxone dispensing are also seen in states like Arizona and Virginia that require clinicians to prescribe naloxone when risk factors for opioid overdose are present. Better access to naloxone should reverse more opioid overdoses and then increase opportunities to link overdose survivors to treatment for opioid dependency. Variation in pharmacy-based naloxone dispensing cannot be fully explained by the need for naloxone. Many factors play a role.

Some of the county-level characteristics associated with being a high naloxone dispensing county were: higher rates of high-dose opioid prescribing; higher rates of drug overdose deaths; and, higher disability prevalence. Rural counties were more likely to be low dispensing, as were counties with higher rates of poverty and higher Medicare enrollment. High out-of-pocket costs may be barriers to people having access to naloxone.  In 2018, more than 30% of naloxone prescriptions required out-of-pocket costs over $50. 71% of Medicare prescriptions required a copay, compared to 42% for commercial insurance.  Our colleagues at the Centers for Medicare and Medicaid Services have been aggressively working to combat the opioid crisis, including exploring ways to make naloxone more available. In April 2019, the centers for Medicare and Medicaid services communicated with Medicare Part D plan sponsors to encourage them to lower cost-sharing for naloxone for patients.

We also examined variation in dispensing by provider specialty in this study. We measured naloxone dispensing per 100 high-dose opioid prescriptions, comparing different specialty groups.

Naloxone prescribing rates were markedly lower among primary care doctors, pain medicine specialists, surgeons, physician assistants, and nurse practitioners. Providers with higher rates of naloxone prescribing per 100 high-dose opioid prescriptions were addiction medicine specialists, psychiatrists, and pediatricians. The variation in prescribing by specialty may be partially explained by differences in the characteristics and overdose risk of patients seen by these specialties. For example, addiction medicine specialists are likely to serve patients at highest risk for overdose due to opioid use disorder and be more familiar with the value of naloxone co-prescribing. Healthcare providers play an important role in educating patients, caregivers, and the community about the benefits of having naloxone readily available. Providers can learn more about how best to communicate with patients about overdose risk and using naloxone by participating in virtual mentoring, academic detailing, or other training on naloxone prescribing and dispensing.

Improving pharmacy dispensing is a key component of greater distribution of naloxone. Our Vital Signs today provide important new information to help us understand trends in dispensing and factors that contribute to persistent variation across the nation. While progress has been made, more action is needed to reduce fatal overdoses through naloxone distribution. We all have a role to play to help improve access to naloxone. Pharmacists and other healthcare providers can ensure that CDC recommendations on prescribing opioids are followed and that naloxone is always stocked in pharmacies. Health insurers, both public and private, can reduce out-of-pockets costs for patients and cover naloxone prescriptions without prior approval. States and communities can work with healthcare providers to expand access to naloxone in rural areas and promote the benefits of prescribing, dispensing, and carrying naloxone. People can ask their doctor or pharmacist for naloxone if they or a loved one are taking high-dose opioids, are co-prescribed benzodiazepines, or have a substance use disorder.

On average, 130 Americans die every day from an opioid overdose. Overdose reversal through naloxone provides an opportunity to save lives, improve the safety and effectiveness of pain management, offer treatment for addiction, prevent future overdose, and improve productivity and quality of life.

Too many people in our country and in our communities are still dying from opioid overdoses. We must do a better job of getting naloxone in the hands of the people who really need it – and those likely to be nearby when an overdose occurs.

MODERATOR: Thank you, Dr. Anne Schuchat. Malinda, I believe we are ready for questions.

OPERATOR: To ask a question, press star-one.  Please unmute your phone and record your name clearly at the prompt.  To withdraw your request, please press star-two.  Once again, please press star-one at this time to ask a question.

One moment, please, for questions.  Questions are coming through.  One moment, please.

Our first question is from Andrew Jacobs, New York Times your line is open.

ANDREW JACOBS, NEW YORK TIMES:  Hi.  Do you see any pattern in states that did not expand Medicaid coverage (inaudible) in terms of Naloxone?

DR. ANNE SCHUCHAT: No, we haven’t looked at the geographic variation that way.  As you can see in the report, we looked at the county level at variation, and we did find characteristics of the county including counties with higher poverty proportions that had less, lower amount of naloxone prescribing.  The issue for insurance, though, is that we saw this important difference between Medicare and commercial insurance in the out-of-pocket or the co-pay costs.  And we know that CMS is working on that.  So, we didn’t look at the data by Medicaid expansion states.  Next question, or did you have a follow-up question?

ANDREW JACOBS, NEW YORK TIMES:  No, that’s good.  Thank you.

DR. ANNE SCHUCHAT: Next question, operator.

OPERATOR: Mike Stobbe, Associated Press.  Your line is open.

MIKE STOBBE, ASSOCIATED PRESS: Hi, thank you for taking my question.  One, I just wanted to double check, what is the cost of naloxone prescription?  I guess it’s commonly a Narcan Kit.  What does that retail for?  And also, I wanted to check for these 556,847 prescriptions in 2018, did that include, you know, in states where there’s standing orders that anyone can get it without a prescription?  Does that include those, too, or is that only in cases where a physician prescribed it?  Thank you.

DR. ANNE SCHUCHAT: Let me take your questions in reverse order.  The database on naloxone prescriptions, the 556,000, that’s everything dispensed at a pharmacy, whether it was by standing order or by a physician prescription.  So — but this doesn’t include the EMS administrations or the community program that provides naloxone.  So it’s not all the naloxone out there.  But it’s a fast rising portion of it.  Now in terms of the cost of naloxone, of course, that will vary in terms of what is charged or the price that the companies negotiate.  But let me put a little more detail on the out-of-pocket costs.  When you look at all of the prescriptions and dispensing that we analyzed, nearly half of the naloxone prescriptions in 2018 did not require any out-of-pocket costs.  25% had an out-of-pocket cost between a penny and $10.  22% had out-of-pocket costs that went between $10 and $50.  And just 6% of all of the prescriptions had out-of-pocket costs over $50.  Now we don’t know what the cost would have been to all the people that didn’t get naloxone, but of the naloxone that was distributed, that was the range.  We do think that reducing out-of-pocket costs is important, and one of the messages today is to encourage private and public insurers to lower those — what they pass along to the consumer.  As you know, that’s a big priority for the administration to address the cost of medication.

DR. ANNE SCHUCHAT: Next question.

OPERATOR: Next question from Eric Grebb from Frontline Medical Communications.  Your line is open.

ERIC GREBB, FRONTLINE MEDICAL COMMUNICATIONS: Hi.  Thank you for taking my question.  You began to get at this in your presentation, but I wanted to ask why you think the number of naloxone prescriptions dispensed is as low as it is despite the high degree of public awareness of the drug’s benefits.

DR. ANNE SCHUCHAT: I think we have a lot more work to do.  This is a priority to provide life-saving rescue medication to people who are at risk for overdose.  And while we’ve seen these important increases, we are not as far along as we’d like to be.  Cost is one of the issues, but I think awareness is another.  That’s a real opportunity today with these new data and the discrepancies we see around the country.  I hope the message for consumers and policymakers and public health and health care providers is to make sure that every pharmacy is stocking naloxone and to make sure that clinicians are thinking about there when they’re prescribing opioids and that patients and their family members are asking about it.  So it’s relatively new that we’ve recommended the co-prescribing and pharmacy dispensing but nearly every state has taken regulation or legal action to promote the accessibility of pharmacy dispensing, and we’d really like to see the increase move much more rapidly.

DR. ANNE SCHUCHAT: Next question, Operator

OPERATOR: Next Question from Zendia Ramen, CQ Roll Call.  Your line is open.

ZENDIA RAMEN, CQ ROLL CALL: Hi, thanks for answering my question.  I was curious if there were any kind of tangible things that could be done to kind of increase the prescribing of naloxone, either from the administration or the states could do or congress could do.  Is there anything that could kind of speed this along?

DR. ANNE SCHUCHAT:  Well, we’ve seen a number of states take action in terms of new regulation or policy, and we do think that state-level policies can have an important impact on naloxone prescriptions.  As I mentioned, Arizona and Virginia appear to have higher naloxone prescribing, and they both have state rules about that.  So that’s something that we hope we’ll be having even more impact as more and more states have come online on that.  There’s also health system issues.  There’s some health care systems that have prompts when a person is prescribing opioids or when a high-dose prescription is put into the system that remind people to check on co-prescribing.  And pharmacies can do the same thing.  So you can sort of automate the reminder to the clinician or the dispenser.  So we do think system and policies can be important, and of course consumer awareness about this.  I think that the availability of the products and formulation that’s are easy for consumers who might be worried about a shot and might be more comfortable with a nasal spray or may be more comfortable with an Epi Pen kind of injection can help with the — overcoming that fear of whether you could save a life.  But we — and we know the Good Samaritan laws can have an impact, as well.  I think there’s action that can be taken locally at the state level and at the federal level. Next question.

OPERATOR: Once again, as a reminder, to ask a question, please press star one at this time.

Next question from Kristi Lee, NBC 10 Boston.  Your line is open.

KRISTI LEE, NBC 10 BOSTON:  Hi, I had a question specific to Massachusetts because that’s the area that I report for.  What is the rate of the naloxone dispensing in Massachusetts, if you have that broken down?  And some of the states specifically.

DR. ANNE SCHUCHAT:  We don’t have the state-specific data broken out.  Massachusetts looks really dark on the map in terms of the counties because they’re reported by county.  But our — our analysts are happy to make available the county-specific data that went into this so that you could get your counties in Massachusetts.  And it does look like they’re a high-prescribing — relatively high prescribing.  We don’t think anybody’s at the level we would like them.  I think through the news website we’ll be able to make sure that people have access to that.  On the map, dark is good basically.  That’s a high — higher dosing — higher naloxone prescriptions per 100,000 persons or per high-dose prescribers in the second map.  Massachusetts is probably doing better than the average part of the country.  When we analyze regionally, the South had the highest rate of naloxone prescribing, and the Midwest had the lowest.  But individual states we didn’t analyze.

KRISTI LEE, NBC 10 BOSTON:  The reasons for the regionally is — you didn’t analyze those either?

DR. ANNE SCHUCHAT:  No.  We analyzed the county analysis by a number of factors.  And as I mentioned, those included prevalence of poverty, the prevalence of disability, Medicaid prevalence, overdose deaths, high-dose prescribing, and a series of factors.  Actually the people north — waver treatment we looked at factors, many of which associated with high or low prescribing.  A state like Massachusetts probably falls into the category of states that were hard hit earlier and are more mature in terms of their statewide programs and policies and may have started to really get the clinician word out about prescribing.

KRISTI LEE, NBC 10 BOSTON:  May I ask one more question?  So why aren’t pediatricians among those prescribing higher rates?  Kind of makes sense with addiction specialists and psychiatrists, but why pediatricians in that group?

DR. ANNE SCHUCHAT:  You know, I wondered the same thing on seeing the results, and I would just be speculating.  But one thing that I wondered was whether they may prescribe opioids less frequently and may be more focused on the safety ratio.  You know, primary care providers are frequent prescribers of opioids but low prescribers of naloxone.  It may be business as usual to them.  Something we’d like to change.  In the pediatric practice you’re not prescribing opioids that often.  That’s total speculation, not backed up by data.  It may be that pediatricians in your state have theories about this to check on.

KRISTI LEE, NBC 10 BOSTON: Thank you.

DR. ANNE SCHUCHAT:  Operator, next question.

OPERATOR:  Thank you.  We are showing no further questions.

MODERATOR: All right.  Okay.  Since we have no further questions, we’ll wrap it up.  Thank you, Dr. Anne Schuchat, for joining us today, and Dr. Guy for being on standby.  If reporters have follow-up questions, you can call us at 404-639-3286, or e-mail us at media@CDC.gov.  Thank you, everyone, for joining us.  This concludes our call.

OPERATOR: Thank you, that does conclude today’s conference.  We appreciate you attending.  You may disconnect at this time.

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