Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose
Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose
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DOI：
10.1001/jamainternmed.2019.0272
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发表时间：
2019-06-01
影响因子：
39
通讯作者：
Powell, David
中科院分区：
文献类型：
--
作者：
Abouk, Rahi;Pacula, Rosalie Liccardo;Powell, David
关键点问题关于纳洛酮获得的州法律是否与减少涉及阿片类药物的致命过量有关？在这项基于人群的研究中，对2005-2016年国家生命统计系统的数据进行了研究，该系统是一种差异设计，旨在评估50个州和哥伦比亚特区，发现采用纳洛酮获取法的州直接授权给药剂师的致命阿片类药物过量的数量在统计上显著下降。其他类型的纳洛酮使用规则似乎与死亡率的降低或增加无关。纳洛酮使用法有可能改善纳洛酮的使用并挽救生命，但法律的细节很重要；允许药剂师在自己的授权下直接配药似乎可以最大限度地发挥这些政策的潜在好处。鉴于与阿片类药物相关的致命过量的高比率，改善纳洛酮的使用已成为当务之急。各州已经实施了不同类型的纳洛酮获取法(NAL)，对于这些政策中的哪些政策(如果有的话)可以遏制过量死亡，存在争议。我们假设，直接授权药剂师提供纳洛酮的NAL将最有潜力减少致命的过量用药。目的确定哪些类型的NAL(如果有)与阿片类药物致命性过量的减少有关，并检查非致命性过量的可能影响。设计、设置和参与者2005年至2016年，在采用非致命药物后，使用差异方法在50个州和哥伦比亚特区检查了致命和非致命过量的州水平变化，同时估计了每年与采用时间的关联程度。主要数据集中显示了整个州人口的政策环境。关联了3种类型的非处方药物：直接授权药剂师开处方的非药物药物，提供间接处方权力的非药物药物，以及其他非药物药物。这项研究于2017年1月至2019年1月进行。对采用NAL法律的州和未采用NAL法律的州的致命性和非致命性过量进行了比较。就其与这些结果的关联而言，进一步审议了所通过的国家法律的类型。我们假设，直接授权药剂师提供纳洛酮的NAL将最有潜力减少致命的过量用药。主要结果和措施涉及阿片类药物的FATA过量是主要结果。次要结果是非致命性过量，导致急诊科就诊和医疗补助纳洛酮处方。结果在这项对全美纳洛酮配药情况的评估中，直接授权给药剂师的NAL与致命过量的显著减少有关，但他们也可能增加急诊科就诊中出现的非致命过量。相对于NALs的采用，致命过量的影响大小随着时间的推移而增长。据估计，这些政策将在采用后3年或更长时间内，每100000人减少0.387(95%CI，0.119-0.656；P=0.007)阿片类药物等级的致命过量。几乎没有证据表明间接权力分配(增加0.121；95%可信区间，-0.014至0.257；P=0.09)和其他不良资产(增加0.094；95%可信区间，-0.040至0.227；P=0.17)之间存在关联。结论和关系尽管许多州已经通过了某种类型的法律来影响纳洛酮的可用性，但似乎只有允许药剂师直接配药的法律才是有用的。获得纳洛酮的机会得到改善的社区应该为非致命过量剂量的增加做好准备，并将这些人与有效的治疗联系起来。这项基于人口的研究审查了各州致命的阿片类药物过量比率，政策允许纳洛酮的药房分销。
Key PointsQuestionAre state laws regarding naloxone access associated with reductions in fatal overdoses involving opioids? FindingsIn this population-based study of data from the 2005-2016 National Vital Statistics System, a difference-in-differences design to evaluate 50 states and the District of Columbia, found that states adopting naloxone access laws granting direct authority to pharmacists experienced statistically significant declines in fatal opioid-related overdoses. Other types of naloxone access laws appear not to be associated with decreases or increases in mortality. MeaningNaloxone access laws have the potential to improve naloxone access and save lives, but the details of the laws matter; permitting pharmacists to dispense directly and under their own authority appears to maximize the potential benefits of these policies.ImportanceGiven high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. ObjectivesTo identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses. Design, Setting, and ParticipantsState-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019. ExposuresFatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses. Main Outcomes and MeasuresFatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions. ResultsIn this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656; P=.007) per 100000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, -0.014 to 0.257; P=.09) and other NALs (increase by 0.094; 95% CI, -0.040 to 0.227; P=.17). Conclusions and RelevanceAlthough many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.This population-based study examines fatal opioid overdose rates in states with policies allowing pharmacy distribution of naloxone.