Incidence of Treatment for Opioid Use Disorder Following Nonfatal Overdose in Commercially Insured Patients

Implementation and maintenance of an emergency department naloxone distribution and peer recovery specialist program

STUDY OBJECTIVE

Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation.

METHODS

We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression.

RESULTS

Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time.

CONCLUSIONS

ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021

STUDY OBJECTIVE

Nonfatal emergency department (ED) visits for opioid overdose are important opportunities to prescribe naloxone and buprenorphine, both of which can prevent future overdose-related mortality. We assessed the rate of this prescribing using national data from August 2019 to April 2021, a period during which US opioid overdose deaths reached record levels.

METHODS

We conducted a retrospective cohort analysis using Symphony Health's Integrated Dataverse, which includes data from 5,800 hospitals and 70,000 pharmacies. Of ED visits for opioid overdose between August 4, 2019, and April 3, 2021, we calculated the proportion with at least 1 naloxone prescription within 30 days and repeated this analysis for buprenorphine. To contextualize the naloxone prescribing rate, we calculated the proportion of ED visits for anaphylaxis with at least 1 prescription for epinephrine-another life-saving rescue medication-within 30 days.

RESULTS

Analyses included 148,966 ED visits for opioid overdose. Mean weekly visits increased 23.6% during the period between April 26, 2020 and October 3, 2020 compared with the period between August 4, 2019 to April 25, 2020. Visits declined to prepandemic levels between October 4, 2020 and March 13, 2021, after which visits began to rise. Naloxone and buprenorphine were prescribed within 30 days at 7.4% and 8.5% of the 148,966 visits, respectively. The naloxone prescribing rate (7.4%) was substantially lower than the epinephrine prescribing rate (48.9%) after ED visits for anaphylaxis.

CONCLUSION

Between August 4, 2019, and April 3, 2021, naloxone and buprenorphine were only prescribed after 1 in 13 and 1 in 12 ED visits for opioid overdose, respectively. Findings suggest that clinicians are missing critical opportunities to prevent opioid overdose-related mortality.

Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation

INTRODUCTION

Black people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients.

METHODS

We identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007-2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice-referred clients.

RESULTS

In expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice-referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non-expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid.

CONCLUSION

The ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice-referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018

Importance

Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population.

Objective

To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation.

Design, Setting, and Participants

This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021.

Main Outcomes and Measures

Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records.

Results

In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001).

Conclusions and Relevance

In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

Emergency Department Utilization Patterns in Patients with Opioid-Related Emergency Department Visits

Opioid-related Emergency Department (ED) visits have surged over the past decade. There is limited data on ED utilization patterns of patients with opioid use disorder (OUD). An improved understanding of utilization may underscore missed opportunities for screening, intervention and referral. This was a retrospective 2:1 matched case-control study conducted at a single urban ED. Cases were patients with an opioid-related index ED visit from June 1, 2017 to May 31, 2018. Controls were patients with a non-opioid related index ED visit from June 1, 2018 to May 31, 2019. The primary outcome was the association between the number of ED visits in the 24-month period surrounding the index visit (12 months prior and 12 months following) and having an opioid-related index ED visit. There were a total of 224 cases. One or more visits preceding (OR: 1.63, 95% CI: 1.17, 2.26) and following the index visit (OR: 2.69, 95% CI: 1.91, 3.78) was significantly associated with case status. Following adjustment, a higher number of visits preceding (aOR: 1.24, 95% CI: 1.08, 1.43) and following the index visit (aOR: 1.39, 95% CI: 1.23, 1.57) remained significantly associated with case status. Patients with an opioid-related index ED visit had significantly higher rates of ED utilization 12 months before and after the index visit when compared to a matched control population. These findings suggest that there are significant opportunities for ED intervention and referral to treatment both prior to and following an opioid-related ED visit in this patient population.

"This is part of emergency medicine now": A qualitative assessment of emergency clinicians' facilitators of and barriers to initiating buprenorphine

OBJECTIVES

Despite evidence demonstrating the safety and efficacy of buprenorphine for the treatment of emergency department (ED) patients with opioid use disorder (OUD), incorporation into clinical practice has been highly variable. We explored barriers and facilitators to the prescription of buprenorphine, as perceived by practicing ED clinicians.

METHODS

We conducted semistructured interviews with a purposeful sample of ED clinicians. An interview guide was developed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework implementation science frameworks. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized.

RESULTS

We interviewed 25 ED clinicians from 11 states in the United States. Participants were diverse with regard to years in practice and practice setting. While outer setting barriers such as the logistic costs of getting a DEA-X waiver and lack of clear follow-up for patients were noted by many participants, individual-level determinants driven by emotion (stigma), beliefs about consequences and roles, and knowledge predominated. Participants' responses suggested that implementation strategies should address stigma, local culture, knowledge gaps, and logistic challenges, but that a particular order to addressing barriers may be necessary.

CONCLUSIONS

While some participants were hesitant to adopt a "new" role in treating patients with medications for OUD, many already had and gave concrete strategies regarding how to encourage others to embrace their attitude of "this is part of emergency medicine now."

Experiences with an addiction consultation service on care provided to hospitalized patients with opioid use disorder: a qualitative study of hospitalists, nurses, pharmacists, and social workers

Background: In response to the opioid epidemic, addiction consultation services (ACS) increasingly provide dedicated hospital-based addiction treatment to patients with substance use disorder. We assessed hospitalist and medical staff perceptions of how the presence of 2 hospitals' ACS impacted care for hospitalized patients with opioid use disorder (OUD). We inquired about ongoing challenges in caring for this patient population.Methods: We conducted a qualitative study of hospital-based providers utilizing focus groups and key informant interviews for data collection. Transcripts were analyzed using a mixed inductive-deductive approach. Emergent themes were identified through an iterative, multidisciplinary team-based process using a directed content analysis approach.Results: Hospitalists (n = 20), nurses (n = 13), social workers (n = 11), and pharmacists (n = 18) from a university hospital and a safety-net hospital in Colorado participated in focus groups or key informant interviews. In response to the availability of an ACS, hospitalists described increased confidence using methadone and buprenorphine to treat opioid withdrawal, which they perceived as contributing to improved patient outcomes and greater job satisfaction. Participants expressed concern about inconsistent care provided to patients with OUD that varied by the admitting team's specialty and the physician's background and training. Nurses and hospitalists reported frustrations with achieving adequate pain control among patients with OUD. Last, pharmacists reported practice variations when physicians dosed buprenorphine for acute pain among patients with OUD. A lack of standardized dosing led to concerns of inadequate analgesia or return to opioid use following hospital discharge.Conclusions: An ACS reportedly supports hospitalists and medical staff to best care for hospitalized patients with OUD. Notably, care provided to patients with OUD may not be uniform depending on various physician-level factors. Future work to address the concerns reported by study participants may include education for OUD treatment, early involvement of the ACS, and incorporation of buprenorphine prescribing algorithms to standardize care.

Interventions for hospitalized medical and surgical patients with opioid use disorder: A systematic review

Background: Concurrent with the opioid overdose crisis there has been an increase in hospitalizations among people with opioid use disorder (OUD), with one in ten hospitalized medical or surgical patients having comorbid opioid-related diagnoses. We sought to conduct a systematic review of hospital-based interventions, their staffing composition, and their impact on outcomes for patients with OUD hospitalized for medical or surgical conditions. Methods: Authors searched PubMed MEDLINE, PsychINFO, and CINAHL from January 2015 through October 2020. The authors screened 463 titles and abstracts for inclusion and reviewed 96 full-text studies. Seventeen articles met inclusion criteria. Extracted were study characteristics, outcomes, and intervention components. Methodological quality was evaluated using the Methodological Quality Rating Scale. Results: Ten of the 17 included studies were controlled retrospective cohort studies, five were uncontrolled retrospective studies, one was a prospective quasi-experimental evaluation, and one was a secondary analysis of a completed randomized clinical trial. Intervention components and outcomes varied across studies. Outcomes included in-hospital initiation and post-discharge connection to medication for OUD, healthcare utilization, and discharge against medical advice. Results were mixed regarding the impact of existing interventions on outcomes. Most studies focused on linkage to medication for OUD during hospitalization and connection to post-discharge OUD care. Conclusions: Given that many individuals with OUD require hospitalization, there is a need for OUD-related interventions for this patient population. Interventions with the best evidence of efficacy facilitated connection to post-discharge OUD care and employed an Addiction Medicine Consult model.

Engaging Disability Rights Law to Address the Distinct Harms at the Intersection of Race and Disability for People with Substance Use Disorder

This article examines the unique disadvantages experienced by Black people and other people of color with substance use disorder in health care, and argues that an intersectional approach to enforcing disability rights laws offer an opportunity to ameliorate some of the harms of oppression to this population.

Variation in emergency department visit rates for opioid use disorder: Implications for quality improvement initiatives

STUDY OBJECTIVE

Emergency departments (ED) are critical touchpoints for encounters among patients with opioid use disorder (OUD), but implementation of ED initiated treatment and harm reduction programs has lagged. We describe national patient, visit and hospital-level characteristics of ED OUD visits and characterize EDs with high rates of OUD visits in order to inform policies to optimize ED OUD care.

METHODS

We conducted a descriptive, cross-sectional study with the 2017 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project, using diagnostic and mechanism of injury codes from ICD-10 to identify OUD related visits. NEDS weights were applied to generate national estimates. We evaluated ED visit and clinical characteristics of all OUD encounters. We categorized hospitals into quartiles by rate of visits for OUD per 1000 ED visits and described the visit, clinical, and hospital characteristics across the four quartiles.

RESULTS

In 2017, the weighted national estimate for OUD visits was 1,507,550. Overdoses accounted for 295,954. (19.6%) of visits. OUD visit rates were over 8× times higher among EDs in the highest quartile of OUD visit rate (22.9 per 1000 total ED visits) compared with EDs in the lowest quartile of OUD visit rate (2.7 per 1000 ED visits). Over three fifths (64.2%) of all OUD visits nationwide were seen by the hospitals in the highest quartile of OUD visit rate. These hospitals were predominantly in metropolitan areas (86.2%), over half were teaching hospitals (51.7%), and less than a quarter (23.3%) were Level 1 or Level 2 trauma centers.

CONCLUSION

Targeting initial efforts of OUD care programs to high OUD visit rate EDs could improve care for a large portion of OUD patients utilizing emergency care.

Factors Associated With Increased Opioid Use During the COVID-19 Pandemic: A Prospective Study of Patients Enrolled in Opioid Agonist Treatment

The opioid use disorder (OUD) crisis in North America has become “an epidemic within a pandemic” in the context of the COVID-19 virus. We aimed to explore the association between the COVID-19 pandemic and changes in opioid use patterns among patients receiving treatment for OUD.

Implementation of buprenorphine initiation and warm handoff protocols in emergency departments: A qualitative study of Pennsylvania hospitals

BACKGROUND

Emergency departments (ED) are a critical touchpoint for patients with opioid use disorder (OUD). In 2019, Pennsylvania had the fifth highest drug overdose mortality rate in the United States. State efforts have focused on implementing evidence-based ED care protocols, including induction of buprenorphine and warm handoffs to community treatment.

OBJECTIVE

We examined hospital staff's perspectives on the processes, challenges, and facilitators to buprenorphine initiation and warm handoff protocols in the ED.

METHODS

We used a qualitative case study design to focus on six Pennsylvania hospitals. The study selected hospitals using purposive sampling to capture varying hospital size, rurality, teaching status, and phase of protocol implementation. The study staff interviewed hospital staff with key roles in OUD care delivery in the ED, which included administrators, physicians, nurses, recovery support professionals, care coordinators, a social worker, and a pharmacist. Guided by the Consolidated Framework for Implementation Research (CFIR), we conducted semi-structured virtual interviews with 21 key informants from June to November 2020. Interviews were transcribed, deductively coded, and analyzed using CFIR domains and constructs to summarize factors influencing implementation of OUD ED care protocols and warm handoff to care protocols, as well as suggestions that emerged between and across cases.

RESULTS

Despite variation in the local context between hospitals, we identified common themes that influenced buprenorphine and warm handoffs across sites. Attention to hospital OUD care through state-level initiatives like the Hospital Quality Improvement Program generated hospital leadership buy-in toward implementing best OUD care practices. Factors at the hospital-level that influenced implementation success included supporting interdisciplinary OUD care champions, addressing knowledge gaps and biases around patients with OUD, having data systems that capture OUD care and integrate clinical protocols, incorporating patient comorbidities and non-medical needs into care, and fostering community provider linkages and capacity for warm handoffs. Although themes were largely consistent among hospital and staff types, protocol implementation was tailored by each hospital's size, patient volume, and hospital and community resources.

CONCLUSIONS

By understanding frontline staff's perspectives around factors that impact OUD care practices in the ED, stakeholders may better optimize implementation efforts.

Barriers to effective care: Specialty drug treatment in Philadelphia

INTRODUCTION

In Philadelphia, the poorest big city in the United States, an estimated 60,000 people misuse opioids and more than 3500 have died of overdose in the past three years. In 2019, fentanyl was detected in 76% of drug-related deaths and 94% of opioid-involved deaths. While much attention has been directed at the public face of the city's drug problem, more than 75% of drug deaths in 2017 took place in a private residence.

METHOD

Based on qualitative research to understand the vulnerabilities of this hidden population of drug users, we interviewed kin of 35 people who had died of opioid overdose in 2017 to learn whether their loved one had interacted with any social services or harm-reduction interventions.

RESULTS

In our demographically and geographically representative sample of decedents, we found that while most had received treatment at least once, many faced barriers to getting treatment when they needed it, including barriers related to stigma, structural racism, gender inequities, bureaucracy, insurance requirements, and cost.

CONCLUSION

We argue that these barriers place an undue burden on people with substance use disorder and their kin during particularly fraught moments of heightened vulnerability. The failure of state and federal policies, practices, and infrastructure to address these barriers, and the failure to require that evidence-based care be provided during treatment have deleterious effects on people affected by the opioid epidemic in the United States.

Facilitators of and barriers to buprenorphine initiation for people with opioid use disorder in the emergency department: protocol for a scoping review

INTRODUCTION

Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation.

METHODS AND ANALYSIS

We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation.

ETHICS AND DISSEMINATION

This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.

Initiation of buprenorphine for opioid use disorder in the hospital setting: Practice models, challenges, and legal considerations

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To provide health-system pharmacists with published examples of strategies utilized to offer buprenorphine to inpatients with opioid use disorder (OUD) along with information on challenges and legal considerations.

SUMMARY

Hospitals and emergency departments (EDs) are a constant source of healthcare for patients with OUD. As a result, hospital practitioners can screen, diagnose, begin treatment, and facilitate transfer of care to the outpatient setting. Offering sublingual buprenorphine in the hospital can bridge the gap before outpatient care is established. Multiple studies have shown that initiating treatment in the ED or during inpatient hospitalization results in 47% to 74% of patients utilizing medication-assisted treatment at day 30 of follow-up, statistically superior to the rates achieved with brief interventions or referral alone. Moreover, initiating buprenorphine treatment in the ED has been shown to decrease healthcare costs. Despite the benefits of offering buprenorphine in the inpatient setting, several challenges must be solved by hospital administration, such as achieving clinician readiness to prescribe buprenorphine, developing relationships with outpatient providers of buprenorphine, and creating an efficient workflow. Treatment of OUD with buprenorphine is heavily regulated on the federal level. Pharmacists can participate in the development of these programs and ensure compliance with applicable laws.

CONCLUSION

As health systems continue to care for patients with OUD, starting buprenorphine in the inpatient setting can improve the transition to outpatient treatment. Several institutions have developed programs with positive results. With an understanding of the typical barriers and relevant laws when initiating buprenorphine in the hospital setting, health-system pharmacists can assist in the development and operation of these initiatives.

Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US

BACKGROUND

This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion.

METHODS

Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors.

RESULTS

After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776).

CONCLUSIONS

Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.

A State Financial Incentive Policy to Improve Emergency Department Treatment for Opioid Use Disorder: A Qualitative Study

OBJECTIVE

In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation.

METHODS

Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals.

RESULTS

The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes.

CONCLUSIONS

A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona

Medication for Opioid Use Disorder (MOUD) is recommended, but not always accessible to those who desire treatment. This study assessed the impact of expanding access to buprenorphine through federally qualified health centers (FQHCs) in Arizona. We calculated mean drive-times to Arizona opioid treatment (OTP) locations, office-based opioid treatment (OBOT) locations, and FQHCs clinics using January 2020 location data. FQHCs were designated as OBOT or non-OBOT clinics to explore opportunities to expand treatment access to non-OBOT clinics (potential OBOTs) to further reduce drive-times for rural and underserved populations. We found that OTPs had the largest mean drive times (16.4 minutes), followed by OBOTs (7.1 minutes) and potential OBOTs (6.1 minutes). Drive times were shortest in urban block groups for all treatment types and the largest differences existed between OTPs and OBOTs (50.6 minutes) in small rural and in isolated rural areas. OBOTs are essential points of care for opioid use disorder treatment. They reduce drive times by over 50% across all urban and rural areas. Expanding buprenorphine through rural potential OBOT sites may further reduce drive times to treatment and address a critical need among underserved populations.

Race, ethnicity, and emergency department post-overdose care

BACKGROUND

Emergency department (ED) visits for opioid-related overdoses continue to rise across the United States, particularly among Black, Latinx, and American Indian/Alaskan Native communities. A minority of people with opioid use disorder (OUD) engages in formal addiction treatment and there are racial disparities in treatment access. ED visits for opioid overdose are crucial opportunities to link individuals with OUD to harm reduction and treatment services. However, we know little about whether racial inequities exist in ED treatment after opioid overdose.

METHODS

This observational, cross-sectional study examined differences in services provided to overdose patients who were discharged after an ED visit for opioid overdose by patient race-ethnicity. Primary outcomes included provision of take-home naloxone, ED-based behavioral counseling, and linkage to treatment. Race-ethnicity differences in post-overdose ED services were evaluated using chi-square analyses, and multivariable logistic regression analyses were conducted to examine associations of race-ethnicity with receiving post-overdose services, controlling for other institutional-, provider-, and patient-level factors.

RESULTS

From September 2017 to February 2020, 734 patients were discharged from the ED for an opioid-related overdose. Most patients were White non-Latinx (70.0%), 8.9% were Black non-Latinx, 3.3% were Other race non-Latinx, and 18.0% were Latinx. Take-home naloxone was the most frequent intervention provided to patients while behavioral counseling was the lowest across all race-ethnicity categories. There were no statistically significant differences in provision of take-home naloxone and treatment referral based on patient race-ethnicity. However, a lower proportion of discharged Black non-Latinx patients received behavioral counseling compared to patients of other race-ethnicities, and the odds of receiving behavioral counseling was significantly higher for White non-Latinx (OR: 1.75; 95% CI: 1.00, 3.06); Latinx (OR: 2.06; 95% CI: 1.05, 4.06); and Other race non-Latinx (OR: 3.29; 95% CI: 1.18, 9.15) patients compared to Black non-Latinx patients.

CONCLUSION

Black non-Latinx patients discharged from the ED for an opioid-related overdose were less likely to receive behavioral counseling compared to non-Black patients. Possible reasons for this decreased provision of behavioral counseling include provider bias, patient mistrust of the medical and behavioral health care systems, and limited provider training in addiction medicine and motivational interviewing. These inequities add to the known racial disparities in ED patient care. Further research should elucidate barriers to behavioral counseling within ED settings and factors contributing to racial inequities in post-overdose emergency care.

Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program

STUDY OBJECTIVE

We retrospectively evaluated the implementation of low-threshold emergency department (ED) buprenorphine treatment at 52 hospitals participating in the CA Bridge Program using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

METHODS

The CA Bridge model included low-threshold buprenorphine, connection to outpatient care, and harm reduction. Implementation began in March 2019. Participating hospitals reported aggregated clinical data monthly after program initiation. Outcomes included identification of opioid use disorder, buprenorphine administration, and linkage to outpatient addiction treatment. Multivariable models assessed associations between hospital location (rural versus urban) and teaching status (clinical teaching hospital versus community hospital) and outcomes in adopting the CA Bridge Program.

RESULTS

Reach: A diverse and geographically distributed group of 52 California hospitals were enrolled in 2 phases (March and August 2019); 12 (23%) were rural and 13 (25%) were teaching hospitals. Effectiveness: Over a 14-month implementation period, 12,009 opioid use disorder patient encounters were identified, including 7,179 (59.7%) where buprenorphine was administered and 4,818 (40.1%) where follow-up visits were attended. Adoption: In multivariable analysis, adoption did not differ significantly between rural and urban or teaching and nonteaching hospitals.

IMPLEMENTATION

By program completion, all 52 (100%) hospitals treated opioid use disorder with buprenorphine; 45 (86.5%) administered buprenorphine after naloxone reversal; 41 (84.6%) offered buprenorphine for inpatients; 48 (92.3%) initiated buprenorphine in pregnant women; and 29 (55.8%) offered take-home naloxone. Maintenance: At 8-month follow-up, all 52 sites reported continued buprenorphine treatment.

CONCLUSION

Low-threshold ED buprenorphine treatment implemented with a harm reduction approach and active navigation to outpatient addiction treatment was successful in achieving buprenorphine treatment for opioid use disorder in diverse California communities.

Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis

The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.

Addressing Racial And Ethnic Disparities In The Use Of Medications For Opioid Use Disorder

Social discourse about the opioid crisis in the US has focused on White populations, even though opioid-related deaths have grown at a higher rate among people of color than among non-Hispanic White people in recent years. Medications for opioid use disorder (OUD) are the gold standard for treating OUD and preventing overdose but are underused among people with OUD, with disproportionately low treatment initiation and retention among people of color. Methadone, which is highly stigmatized and has a more burdensome treatment regimen, is the predominant medication for OUD available to people of color. To address disparities in the initiation and retention of treatment using medication for OUD, policy makers should consider strategies such as Medicaid expansion, increased grant funding for federally qualified health centers to provide buprenorphine treatment, retention of temporary telehealth policies that allow remote buprenorphine induction, and regulatory changes to allow methadone treatment in office-based practices.

Opioid use disorder and health service utilization among COVID-19 patients in the US: A nationwide cohort from the Cerner Real-World Data

BACKGROUND

Both opioid use and COVID-19 affect respiratory and pulmonary health, potentially putting individuals with opioid use disorders (OUD) at risk for complications from COVID-19. We examine the relationship between OUD and subsequent hospitalization, length of stay, risk for invasive ventilator dependence (IVD), and COVID-19 mortality.

METHODS

Multivariable logistic and exponential regression models using electronic health records data from the Cerner COVID-19 De-Identified Data Cohort from January through June 2020.

FINDINGS

Out of 52,312 patients with COVID-19, 1.9% (n=1,013) had an OUD. COVID-19 patients with an OUD had higher odds of hospitalization (aOR=3.44, 95% CI=2.81-4.21), maximum length of stay ( e β ^ =1.16, 95% CI=1.09-1.22), and odds of IVD (aOR=1.26, 95% CI=1.06-1.49) than patients without an OUD, but did not differ with respect to COVID-19 mortality. However, OUD patients under age 45 exhibited greater COVID-19 mortality (aOR=3.23, 95% CI=1.59-6.56) compared to patients under age 45 without an OUD. OUD patients using opioid agonist treatment (OAT) exhibited higher odds of hospitalization (aOR=5.14, 95% CI=2.75-10.60) and higher maximum length of stay ( e β ^ =1.22, 95% CI=1.01-1.48) than patients without OUDs; however, risk for IVD and COVID-19 mortality did not differ. OUD patients using naltrexone had higher odds of hospitalization (aOR=32.19, 95% CI=4.29-4,119.83), higher maximum length of stay ( e β ^ =1.59, 95% CI=1.06-2.38), and higher odds of IVD (aOR=3.15, 95% CI=1.04-9.51) than patients without OUDs, but mortality did not differ. OUD patients who did not use treatment medication had higher odds of hospitalization (aOR=4.05, 95% CI=3.32-4.98), higher maximum length of stay ( e β ^ =1.14, 95% CI=1.08-1.21), and higher odds of IVD (aOR=1.25, 95% CI=1.04-1.50) and COVID-19 mortality (aOR=1.31, 95% CI=1.07-1.61) than patients without OUDs.

INTERPRETATION

This study suggests people with OUD and COVID-19 often require higher levels of care, and OUD patients who are younger or not using medication treatment for OUDs are particularly vulnerable to death due to COVID-19.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in Texas, USA

BACKGROUND AND AIMS

Patients with opioid use disorder (OUD) must be able to obtain prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) from a pharmacy promptly to reduce risk for a recurrence of use and subsequent morbidity and mortality. Telephone audits have identified concerning gaps in availability of NNS within US pharmacies, but the availability of BUP/NX has not been rigorously evaluated. This study estimated the availability of BUP/NX and NNS in the US state of Texas and compared availability by pharmacy type and metropolitan status.

DESIGN

A cross-sectional telephone audit with a secret shopper approach conducted from 18 May 2020 to 7 June 2020. Setting and Participants A random sample of 800 of 5078 (16%) community pharmacies licensed with the Texas State Board of Pharmacy.

MEASUREMENTS

Primary outcomes included availability of a 1-week supply of generic BUP/NX 8/2 mg films and a single unit of NNS 4 mg, overall and by pharmacy type. Secondary outcomes included willingness and estimated time-frame to order BUP/NX if unavailable.

FINDINGS

Data from 704 pharmacies (471 chain, 233 independent) were included for analyses. Of these, 34.1% of pharmacies (45.0% of chains versus 12.0% of independents, P < 0.0001) were willing and able to dispense a 1-week supply of generic BUP/NX and a single unit of NNS. BUP/NX alone was available in 42.2% of pharmacies (52.4% of chains versus 21.5% of independents, P < 0.0001). NNS alone was available in 60.1% of pharmacies (77.9% of chains versus 24.0% of independents, P < 0.0001). Of the 397 pharmacies with generic BUP/NX unavailable, 62.2% of pharmacies (73.9% of chains versus 48.0% of independents, P < 0.0001) indicated willingness to order.

CONCLUSIONS

Most pharmacies in Texas do not appear to be willing and able to dispense prescribed buprenorphine/naloxone films and naloxone nasal spray to patients with opioid use disorder in a timely manner. Deficiencies in availability are markedly more pronounced in independent pharmacies compared with chain pharmacies.

Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care

BACKGROUND

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.

METHODS

The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.

RESULTS

PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.

CONCLUSION

Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Hospital Care for Opioid use in Illinois, 2016-2019

This study analyzes trends in hospital emergency room visits and admissions for patients with opioid diagnoses seen at 214 hospitals in Illinois over 42 months. Visits were coded hierarchically for opioid overdose, dependence, abuse, or use. Visit rates per 100,000 were stratified by zip code level of poverty. Regression estimates of the likelihood of inpatient admission and death are presented. There were 239,069 visits accounting for almost $5 billion in total charges and over 710,000 inpatient hospital days with less than a 1% death rate. The Illinois opioid epidemic is concentrated in the poorest areas of the Chicago metropolitan area. There was a sharp gradient in visits rates and deaths rates by poverty level area and more than a fivefold difference in hospital deaths. Effective state policy responses should expand to include decriminalization and proven harm reduction strategies such as medically assisted treatment, access to safe syringes, take home naloxone, and supervised safe consumption facilities.