Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings

ABSTRACT

Background: The United States is facing an epidemic of opioid use and misuse leading to historically high rates of overdose. Community-based overdose education and naloxone distribution has effectively trained lay bystanders to recognize signs of overdose and administer naloxone for reversal. There has been a movement to encourage physicians to prescribe naloxone to all patients at risk of overdose; however, the rate of physician prescribing remains low. This study aims to describe resident knowledge of overdose risk assessment, naloxone prescribing practices, attitudes related to naloxone, and barriers to overdose prevention and naloxone prescription. Methods: The HOPE (Hospital-based Overdose Prevention and Education) Initiative is an educational campaign to teach internal medicine residents to assess overdose risk, provide risk reduction counseling, and prescribe naloxone. As part of a needs assessment, internal medicine residents at an academic medical center in Baltimore, Maryland, were surveyed in 2015. Data were collected anonymously using Qualtrics. Results: Ninety-seven residents participated. Residents were overwhelmingly aware of naloxone (80%) and endorsed a willingness to prescribe (90%). Yet despite a high proportion of residents reporting patients in their panels at increased overdose risk (79%), few had prescribed naloxone (15%). Residents were willing to discuss overdose prevention strategies, although only a minority reported doing so (47%). The most common barriers to naloxone prescribing were related to knowledge gaps in how to prescribe and how to assess risk of overdose and identify candidates for naloxone (52% reporting low confidence in ability to identify patients who are at risk). Conclusions: Medicine residents are aware of naloxone and willing to prescribe it to at-risk patients. Due to decreased applied knowledge and limited self-efficacy, few residents have prescribed naloxone in the past. In order to improve rates of physician prescribing, initiatives must help physicians better assess risk of overdose and improve prescribing self-efficacy.

KEYWORDS:

• Drug overdose
• medical education
• naloxone

Acknowledgments

Dr. Hoover Adger and Dr. Susan Sherman provided valuable support on construction of the survey instrument and research design. The Urban Health Internal Medicine-Pediatrics residents provided feedback essential in the design and creation of the HOPE Initiative. The authors declare that they have no conflicts of interest.

Funding

This work was supported by a grant from the Johns Hopkins Hospitalist Scholars Program. Dr. J. Deanna Wilson was supported through two training awards: the HRSA/MCH/T71MC08054 and T32HD052459-07. Dr. Pamela Matson was supported through NIH K01DA035387. It had no role in the design, conduct, collection, management, analysis, or interpretation of the data. There was no communication about preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication. The funder solely received a summary of the proposed project at the project's inception.

Author contributions

J. D. Wilson conceptualized and designed the HOPE Initiative and needs assessment; she collected the data, completed data analysis, and drafted portions of the manuscript. N. Spicyn aided in design of the HOPE Initiative, design of the survey instrument, and drafted portions of the manuscript. P. Matson contributed to analysis of the data and revision of the manuscript. A. Alvanzo drafted and revised portions of the manuscript. L. Feldman participated in the design of the HOPE Initiative and revision of the manuscript. All authors read and approved the final manuscript.