The continued toll of opioid-related overdoses has motivated efforts to expand availability
of naloxone to persons at high risk of overdose, with 2016 federal guidance encouraging
clinicians to co-prescribe naloxone to patients with increased overdose risk. Some
states have pursued analogous or stricter legal requirements that could more heavily
influence prescriber behavior. We conducted a systematic legal review of state laws
that mandate or recommend that healthcare providers prescribe naloxone to patients
with indicators for opioid overdose risk. We coded relevant statutes and regulations
for: applicable populations, patient criteria, educational requirements, and exemptions.
As of September 2019, 17 states had enacted naloxone co-prescribing laws, the earliest
of which was implemented by Louisiana in January 2016. If patient overdose risk criteria
are met, over half of these states mandate that providers prescribe naloxone (7 states,
41.1 %) or offer a naloxone prescription (2 states, 11.8 %); the remainder encourage
prescribers to consider prescribing naloxone (8 states). Most states (58.8 %) define
patient overdose risk based on opioid dosages prescribed, although the threshold varies
substantially; other common overdose risk criteria include concomitant opioid and
benzodiazepine prescriptions and patient history of substance use disorder or mental
illness. A growing minority of states has adopted a naloxone prescribing law, although
these policies remain less prevalent than other naloxone access laws. By targeting
higher-risk patients during clinical encounters, naloxone prescribing requirements
could increase naloxone prescribed, destigmatize naloxone use, and reduce overdose
harms. Further investigation into policy effectiveness, unintended consequences, and
appropriate parameters is warranted.