The federal health agency serving federally recognized tribal members achieved its goal of reducing opioid prescriptions. But the majority of Indigenous patients considered to be at risk of an opioid overdose were not prescribed naloxone, the medication capable of reversing it, in a contradiction of agency policy, a watchdog has found.
This finding was buried in a December 9 report by the Health and Human Services’ Office of the Inspector General (HHS-OIG) on the claimed success of the Indian Health Service’s (IHS) reduced opioid prescriptions: 60 percent of Indigenous patients on high doses of opioids—a group deemed at risk of overdose—did not receive agency-recommended naloxone co-prescriptions from IHS-run pharmacies.
Although the HHS does not operate other direct medical service subagencies, and thus does not have comparable non-Indigenous data, the watchdog has, in the past, found that a smaller proportion of Medicare recipients than IHS patients were co-prescribed naloxone. “23 percent of the Medicare Part D beneficiaries at serious risk [of overdose] in 2017 received naloxone prescriptions through Medicare Part D in 2017 or 2018,” an HHS-OIG spokesperson told Filter.
Indigenous people in the United States are one of the communities hit hardest by opioid-involved overdoses, though pharmaceuticals are no longer driving them. In 2017, Indigenous people suffered the second highest overall rate of fatal overdoses of any demographic.
On the state level, the disparity becomes even starker. In 2019, Indigenous Minnesotans were seven times more likely to die from an overdose than whites, and the gap is only increasing, according to the state’s health department. From 2013 to 2015, for example, the rate of fatal drug overdoses in Washington state was 2.7 times higher for people classified as American Indians and Alaska Natives than for non-Hispanic whites, according to a 2018 Centers for Disease Control and Prevention report. That disparity grew to 4.1 times higher when considering only heroin-involved overdoses.
The absolute number of IHS patients on high dosages—defined as a morphine milligram equivalent (MME), a standardized measurement unit to compare opioid strengths, of more than 120 milligrams daily for three months—is relatively small: 159 patients, or under 1 percent of IHS patients receiving prescribed opioids at an agency pharmacy.
The IHS guidelines “highly recommend” the co-prescription of naloxone for patients receiving 50 MME per day or more. They add, in their definition of naloxone, that “[p]atients taking high doses of opioid medications can suffer lethargy, somnolence, unconsciousness, respiratory failure or death if they do not receive prompt intervention with this reversal agent.”
Although the HHS-OIG made recommendations to increase automation of prescription monitoring and utilization of state prescription drug monitoring programs, it did not make any recommendations regarding naloxone co-prescribing. The report noted that these patients may be accessing naloxone through non-IHS services. The IHS’s spokespeople didn’t respond to Filter‘s request for comment by publication time.
Photo of a sign at Parker Indian Health Center Indian Health Service via Public Domain