Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes

What happens after the funding ends?: A qualitative sustainability investigation of emergency department-based peer support programs implemented as part of Indiana's opioid state targeted response initiative

INTRODUCTION

In 2017, funding disseminated through the US Substance Abuse and Mental Health Services Administration's Opioid State Targeted Response (STR) program accelerated the expansion of peer recovery support services across several states to engage emergency department patients presenting with opioid use disorder. While there is some literature on the initial implementation of these programs, little is known about their sustainability after the STR funding's end. Identifying what happened to these programs is a key component of understanding their ultimate impact and can inform future activities to develop, fund, or sustain similar efforts.

METHODS

We collected qualitative data from six organizations that participated in Indiana's STR-funded Recovery Coaching and Peer Support Initiative (RCPSI). The semi-structured interview guide was designed to gather data related to eight domains of sustainability (i.e., environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, program evaluation, communications, and strategic planning). The analysts followed a deductive-inductive analysis approach, using the eight domains as an a priori coding structure and developing higher-level inductive themes.

RESULTS

A total of ten individuals (roles included 4 Program Supervisors, 2 Nurse Administrators, a Psychiatric Social Worker, a Mobile Treatment Manager, a Grant Coordinator, and a Vice President of Planning) participated in six interviews. Two programs did not sustain services, primarily because they lacked a sufficient volume of eligible patients to justify services. Factors identified as supporting sustainability in the other four programs included (1) identification of alternate funding sources, (2) evolving internal support for ED-based opioid use disorder treatment, and (3) investment in internal and external relationships. Furthermore, these themes operated across multiple sustainability domains.

CONCLUSIONS

The findings illustrate a dynamic interplay between program context and multiple theorized sustainability domains that impacted the viability of RCPSI programs after the end of STR funding. Results indicate a need for a better understanding of the factors influencing the sustainability of programs supported by federal funding to mitigate the opioid crisis, and such findings will likely apply to a broader range of grant-supported programs.

Descriptive Analysis of Emergency Department Patients With Substance Use Disorders As Seen by Peer Recovery Specialists in Philadelphia

BACKGROUND

People with substance use disorders have regular contact with the emergency department (ED). Peer recovery specialists with lived experiences of substance use can provide critical linkages to substance use treatment and other services for patients who use drugs. Patient populations seen by peer recovery specialists remain largely undescribed.

OBJECTIVE

This paper describes the demographics, substance use patterns, and barriers to treatment of patients seen by peer recovery specialists in an ED in Philadelphia.

METHOD

A review of patient records about demographics, the reason for ED visits, housing, primary drug of choice, previous treatment, treatment barriers, and urine toxicology screening results was conducted.

RESULTS

Of 228 patients seen between December 1, 2020, and April 8, 2021, those who listed alcohol as their drug of choice (n=56, 24.6%) came to the ED primarily for withdrawal symptoms (n=19, 33.9%). Patients who listed other drug use (n=172, 75.4%) were largely seen for infection (n=57, 33.1%). Polysubstance use was prevalent in patients whose primary drugs of choice were not alcohol. Inpatient treatment was the most common previous treatment previously (n=106, 46.5%) and the most desired treatment preferred for future treatment (n=97, 42.5%). The most common barriers to treatment for patients were medical comorbidities (n=70, 30.7%) and difficulty navigating the healthcare system (n=43, 18.9%).

CONCLUSIONS

Patients consulted by peer recovery specialists had distinct demographics, substance use patterns, and perceived goals and barriers to care. These findings highlight the importance of recognizing and treating polysubstance use for people who use drugs and the critical role of peer recovery programs in navigating subsequent care.

Peer support for patients with opioid use disorder in the emergency department: A narrative review

Faced with a growing opioid overdose crisis, emergency departments (EDs) are increasingly hiring peers-people with lived experiences of addiction and recovery-to work with patients in the ED who have opioid use disorders (OUDs) or who have experienced an opioid overdose. Despite a clear need for more support for patients with OUD and rapid expansion in grant funding for peer programs, there are limited data on how these programs affect clinical outcomes and how they are best implemented within the ED. In this narrative review, we synthesize the existing evidence on how to develop and implement peer programs for OUD in the ED setting. We describe the key activities peers can undertake in the ED, outline requirements of the peer role and best practices for peer supervision and hiring, detail how ED administrators have built financial and political support for peer programs, and summarize the limited evidence on clinical and care linkage outcomes of peer programs. We highlight key resources that ED clinicians and administrators can use to develop peer programs and key areas where additional research is needed.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial

BACKGROUND AND AIMS

Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose.

DESIGN

Two-arm, randomized trial.

SETTING

Two EDs in Rhode Island, USA.

PARTICIPANTS

ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White.

INTERVENTION AND COMPARATOR

Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW).

MEASUREMENTS

We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period.

FINDINGS

Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11).

CONCLUSIONS

In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

Results From the POINT Pragmatic Randomized Trial: An Emergency Department-Based Peer Support Specialist Intervention to Increase Opioid Use Disorder Treatment Linkage and Reduce Recurrent Overdose

BACKGROUND

People with opioid use disorder (OUD) frequently present at the emergency department (ED), a potentially critical point for intervention and treatment linkage. Peer recovery support specialist (PRSS) interventions have expanded in US-based EDs, although evidence supporting such interventions has not been firmly established.

METHODS

Researchers conducted a pragmatic trial of POINT (Project Planned Outreach, Intervention, Naloxone, and Treatment), an ED-initiated intervention for harm reduction and recovery coaching/treatment linkage in 2 Indiana EDs. Cluster randomization allocated patients to the POINT intervention (n = 157) versus a control condition (n = 86). Participants completed a structured interview, and all outcomes were assessed using administrative data from an extensive state health exchange and state systems. Target patients (n = 243) presented to the ED for a possible opioid-related reason. The primary outcome was overdose-related ED re-presentation. Key secondary outcomes included OUD medication treatment linkage, duration of medication in days, all-cause ED re-presentation, all-cause inpatient re-presentation, and Medicaid enrollment. All outcomes were assessed at 3-, 6-, and 12-months post-enrollment. Ad hoc analyses were performed to assess treatment motivation and readiness.

RESULTS

POINT and standard care participants did not differ significantly on any outcomes measured. Participants who presented to the ED for overdose had significantly lower scores (3.5 vs 4.2, P < .01) regarding readiness to begin treatment compared to those presenting for other opioid-related issues.

CONCLUSIONS

This is the first randomized trial investigating overdose outcomes for an ED peer recovery support specialist intervention. Though underpowered, results suggest no benefit of PRSS services over standard care. Given the scope of PRSS, future work in this area should assess more recovery- and harm reduction-oriented outcomes, as well as the potential benefits of integrating PRSS within multimodal ED-based interventions for OUD.

Naloxone distribution programs in the emergency department: A scoping review of the literature

This scoping review summarized the literature regarding naloxone distribution from emergency departments (EDs) without a prescription. Our intention was to examine various naloxone distribution programs, their methodologies, and the level of effectiveness of each. Understanding these key aspects of naloxone distribution could lead to improved standardized protocols, saving countless additional lives from opioid overdose. This review evaluated studies reporting naloxone distribution from EDs in the United States. The included studies were written in English and published between January 1, 2017, and December 31, 2022. Searches were performed using PubMed and Embase. A total of 129 studies were reviewed, with only 12 meeting the necessary criteria for analysis. Heterogeneity was found across naloxone distribution programs, including how patients were identified, how naloxone was dispensed to patients, and the specific naloxone products made available. The protocols included various methods, such as patient screening, where information used for this screening was sometimes obtained from health records or patient interviews. Some programs detailed only the distribution of naloxone, while others included additional interventions such as behavior counseling, peer support, and education. In four studies, patients received buprenorphine with naloxone kits. The various programs differed in their implementation but were generally successful in improving naloxone distribution. However, among the studies reviewed, the percentage of ED patients receiving naloxone varied from ∼30% to 70%, suggesting that certain program elements may be more impactful. Further research is needed to identify key elements of the most impactful programs in order to improve naloxone distribution and improve patient odds of surviving an opioid overdose.

Attitudes toward medications for opioid use disorder among peer recovery specialists

Background: Peer recovery specialists (PRSs) are substance use service providers with lived experience in recovery. Although a large body of research demonstrates the efficacy of medications for opioid use disorder (MOUD), emerging research suggests PRSs' attitudes toward MOUD are ambivalent or mixed. Few studies have quantitatively assessed factors influencing PRSs' attitudes.Objectives: This study identifies personal and professional characteristics associated with attitudes toward MOUD among PRSs.Methods: PRSs working at publicly funded agencies in Michigan completed a self-administered web-based survey (N = 266, 60.5% women). Surveys assessed socio-demographics, treatment and recovery history, attitudes toward clients, and attitudes toward MOUD. Multiple linear regression was used to identify factors associated with attitudes toward MOUD.Results: A minority of PRSs (21.4%) reported a history of treatment with MOUD, while nearly two-thirds reported current 12-step involvement (62.5%). Compared to PRSs without a history of MOUD treatment, PRSs who had positive (b = 4.71, p < .001) and mixed (b = 3.36, p = .010) experiences with MOUD had more positive attitudes; PRSs with negative experiences with MOUD had less positive attitudes (b = -3.16, p = .003). Current 12-step involvement (b = -1.63, p = .007) and more stigmatizing attitudes toward clients (b = -.294, p < .001) were associated with less positive attitudes toward MOUD. Black PRSs had less positive attitudes than White PRSs (b = -2.50, p = .001), and women had more positive attitudes than men (b = 1.19, p = .038).Conclusion: PRSs' attitudes toward MOUD varied based on the nature of their lived experience. Findings highlight considerations for training and supervising PRSs who serve individuals with opioid use disorder.

Latent class analysis of emergency department patients engaged in telehealth peer recovery support services and associations of identified classes with post-discharge outcomes

BACKGROUND

People with substance use disorders (SUDs) frequently use emergency department (ED) services. Despite evidence demonstrating that post-discharge SUD treatment linkage effectively reduces the number of ED re-presentations, relatively few hospitals have implemented interventions to identify and connect patients with SUDs to appropriate care. ED-based peer recovery support specialist (PRSS) interventions have emerged as a promising approach for hospitals, but more research is needed to understand the extent to which these interventions meet the needs of patients who present to the ED for different reasons and with various underlying concerns.

METHOD

A retrospective cohort analysis used data from a telehealth PRSS program in 15 EDs within one Indiana hospital system. The study included 2950 ED patients who engaged with telehealth PRSS services between September 2018 and September 2021. Latent class analysis identified patterns of patient characteristics associated with post-discharge PRSS engagement and ED re-presentations. Covariate predictors and distal outcomes were assessed to examine the associations between class membership, demographic factors, and patient outcomes.

RESULTS

The study team selected a six-class model as the best fit for the data. Class 1, representing patients with opioid use disorder and mental health diagnoses who presented to the ED for an opioid overdose, was used as the reference class for all other statistical tests. Multinomial logistic regression analysis demonstrated significant associations between covariate predictors, outcomes, and class membership. Regression results also demonstrate PRSSs had greater success contacting patients with prior year ED use and patients with a successful post-discharge PRSS contact were less likely to re-present to the ED.

CONCLUSION

Results highlight the heterogeneity of patients with SUDs and emphasize the need for tailored interventions to address patient-specific needs more effectively. They also provide support for the perceived utility of PRSS engagement for ED patients.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Barriers and Best Practices on the Management of Opioid Use Disorder

Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.

Evaluation of video-assisted HPV education in government-supported clinics in Western Kenya

Despite prevalent preventative methods of human papillomavirus (HPV), cervical cancer remains the foremost cause of cancer-related death among women of reproductive age in Western Kenya. HPV self-sampling is a preventative measure that can improve accessibility and availability to cervical cancer screening. Correct education about HPV is crucial to combating stigma and increasing HPV screening uptake. In this study, we evaluated the workflow impact of a video-assisted HPV education to promote self-sampling in clinical settings in Kisumu, Kenya. We conducted a descriptive workflow study nested in a two-part cluster-randomized control trial in six government-supported health clinics in Kisumu County. We observed the workflow of HPV screening video-assisted and standard health educations. and evaluated community and clinic health assistant facilitation (CCHA), duration, and feasibility of the intervention. Thirty HPV screening-eligible women who participated in the video intervention were recruited for three focus group discussions (FGDs). The FGDs aimed to better understand women's experience with the video screening, their impressions on the content, and feedback about intervention logistics. Across 33 observations, 16.5 women per day watched the educational video at intervention clinics, and 14 women per day heard standard Ministry of Health cervical cancer prevention education talks at control clinics. Sixty-three percent of women participated in HPV self-sampling in the intervention sites, compared to forty-six percent who screened after standard health talks at control sites. The workflow observations identified variable video projection and viewing space, access to power supply, and CCHA availability and ability to utilize the projector as major factors impacting education workflow. Women in FGDs appreciated the video modality, length of video, and education location. HPV video education is a suitable intervention, with further research recommended to determine the viability of sustainably implementing the intervention in a clinic environment. This research is fully funded by the Duke University Global Health Institute.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

BACKGROUND

People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.

METHODS

A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.

FINDINGS

The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.

CONCLUSION

This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

What makes a peer? Characteristics of certified peer recovery support specialists in an emergency department-based intervention

Providing brief interventions by certified peer recovery support specialists (CPRSS) in the emergency department (ED) following a drug related visit is a promising method of service engagement and has garnered national attention. This study examines CPRSS's perceptions of the qualities that enable them to deliver interventions in the ED. We conducted qualitative interviews with 14 CPRSSs working in EDs. Interview topics included how the participants became involved with CPRSS work, experiences working in the ED, how the ED differs from other settings, and what interactions with patients look like. Interviews were digitally recorded, transcribed, and analyzed for emerging categories. Three categories were identified relating to CPRSS work: (1) how they approach peer work, (2) inherent qualities required to do the work, regardless of the setting, and (3) context-specific skills required to do the work in the ED. When describing their approach to this work, participants talked about CPRSS work as their life calling and their passion. Participants also identified certain qualities that all CPRSS workers possess, regardless of the setting, including the ability to build rapport, strong listening skills, and a shared lived experience. Lastly, participants identified how specific hard and soft skills help them to navigate organizational and structural challenges in the ED. The unique conditions of the ED and the required qualities of a CPRSS should be considered when implementing an ED-based intervention.

Ambivalence and contingencies: A qualitative examination of peer recovery coaches' attitudes toward medications for opioid use disorder

INTRODUCTION

Peer recovery coaches (PRCs) are an important provider group affecting medications for opioid use disorder (MOUD) uptake and retention. However, some PRCs may have experiences and beliefs that do not align with the use of MOUD. This study examines PRCs' perceptions of MOUD and how PRCs' attitudes affect their interactions with clients. The article also explores factors influencing PRCs' attitudes.

METHODS

The study team conducted semi-structured interviews by phone with PRCs in Michigan (N = 34, July through September 2021). The study asked participants about their opinion of MOUD, how they help clients to make decisions about MOUD, and whether they have encountered negative attitudes toward MOUD in their work. Data analysis was guided by Tracy's (2020) iterative phronetic approach.

RESULTS

Nearly all PRCs acknowledged the social stigma surrounding MOUD. PRCs described the stigma toward MOUD as affecting treatment access, utilization, and recovery support. While most PRCs expressed support for many recovery pathways, support for MOUD was contingent on the type of medication and the conditions under which it is used. PRCs often described MOUD as acceptable only in the short-term when paired with psychosocial interventions, after nonpharmacological treatment attempts had failed. PRCs with concerns about MOUD reported sometimes avoiding discussions about MOUD with clients, spreading misinformation about MOUD, and encouraging clients to discontinue treatment. However, many PRCs expressed a desire to support clients' self-determination despite their own biases.

CONCLUSIONS

Findings highlight a need for education and stigma reduction among PRCs and point to specific areas for intervention. PRCs described deeply engrained beliefs about MOUD rooted in their own treatment histories and recovery practices. Provision of high-quality training and supervision to shift attitudes among PRCs will be key to increasing the use of MOUD.

The association between community social vulnerability and prescription opioid availability with individual opioid overdose

BACKGROUND

This study aims to assess the association of community social vulnerability and community prescription opioid availability with individual non-fatal or fatal opioid overdose.

METHODS

We identified patients 12 years of age or older from the Oregon All Payer Claims database (APCD) linked to other public health datasets. Community-level characteristics were captured in an exposure period (EP) (1/1/2018-12/31/2018) and included: census tract-level social vulnerability domains (socio-economic status, household composition, racial and ethnic minority status, and housing type and transportation), census tract-level prescriptions and community-level opioid use disorder (OUD) diagnoses per 100 capita binned into quartiles or quintiles. We employed Cox models to estimate the risk of fatal and non-fatal opioid overdoses events in the 12 months following the EP.

MAIN FINDINGS

We identified 1,548,252 individuals. Patients were mostly female (54%), White (61%), commercially insured (54%), and lived in metropolitan areas (81%). Of the total sample, 2485 (0.2%) experienced a non-fatal opioid overdose and 297 died of opioid overdose. There was higher hazard for non-fatal overdose in communities with greater OUD per 100 capita. We also found higher non-fatal and fatal hazards for opioid overdose among patients in communities with higher housing type and transportation-related vulnerability compared to the lowest quintile. Conversely, patients were at less risk of opioid overdose when living in communities with greater prevalence of the young or the elderly, the disabled, single parent families or low English proficiency.

CONCLUSION

These findings underscore the importance of the environmental context when considering public health policies to reduce opioid harms.

National Institute on Drug Abuse Clinical Trials Network Meeting Report: Advancing Emergency Department Initiation of Buprenorphine for Opioid Use Disorder

Opioid use disorder and opioid overdose deaths are a major public health crisis, yet highly effective evidence-based treatments are available that reduce morbidity and mortality. One such treatment, buprenorphine, can be initiated in the emergency department (ED). Despite evidence of efficacy and effectiveness for ED-initiated buprenorphine, universal uptake remains elusive. On November 15 and 16, 2021, the National Institute on Drug Abuse Clinical Trials Network convened a meeting of partners, experts, and federal officers to identify research priorities and knowledge gaps for ED-initiated buprenorphine. Meeting participants identified research and knowledge gaps in 8 categories, including ED staff and peer-based interventions; out-of-hospital buprenorphine initiation; buprenorphine dosing and formulations; linkage to care; strategies for scaling ED-initiated buprenorphine; the effect of ancillary technology-based interventions; quality measures; and economic considerations. Additional research and implementation strategies are needed to enhance adoption into standard emergency care and improve patient outcomes.

A randomized control trial of a combined community health worker and re-entry intervention for people with HIV recently released from jail who use substances

INTRODUCTION

People with human immunodeficiency virus (HIV; PWH) who use substances are disproportionately involved in the criminal justice system. While HIV viral suppression typically improves during incarceration, these gains are frequently lost after release. We evaluated the impact of a combined intervention (formerly incarcerated community health workers [CHW] plus a re-entry organization; CHW+) on postrelease HIV- and substance use-related outcomes.

METHODS

We conducted a pilot randomized controlled trial of a CHW+ for PWH who use substances, within 30 days of release from a large southern, urban jail. Between February 2019 and August 2021, participants were recruited, enrolled, and randomized to treatment as usual (TAU; passive referral to care) or CHW+. Follow up study visits occurred at 3, 6, and 12 months. The primary outcome was HIV VL at 6 months; secondary outcomes included 6-month urinary toxicology and high-risk substance use at 12 months.

RESULTS

A total of 31 participants were enrolled who were primarily male (n = 24; 77 %), Black (n = 22; 71 %), unemployed (n = 23; 74.2 %), had unstable housing (n = 18; 58 %), had food insecurity (n = 14; 45 %), and reported their drug of choice was stimulants (n = 24; 77 %). The study identified no significant difference in HIV VL suppression at 6 months (20 % v. 37 %; [CHW+ v. TAU], p = 0.61). We observed improved substance use outcomes in CHW+ v. TAU, including fewer positive urinary toxicology screens for stimulants (40 % v. 100 %; p = 0.01) and a trend toward less high-risk substance use (30 % v. 43 %). The CHW+ group met more basic needs, such as food security [+32 % v. +11 %], housing security [+52 % v. -7 %] and full-time employment [+20 % v. +5 %] compared to TAU.

CONCLUSIONS

PWH who use substances assigned to a combined intervention of CHW+ after jail release did not achieve higher rates of HIV VL suppression than TAU; however, they had improved substance use outcomes and met more basic subsistence needs. Results highlight the potential of culturally informed interventions to address the competing needs of PWH who use substances after release from jail and call for further development of innovative solutions to successfully bridge to HIV care in the community.

The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments

OBJECTIVE

Opioid-related overdose (OD) deaths continue to increase. Take-home naloxone (THN), after treatment for an OD in an emergency department (ED), is a recommended but under-utilized practice. To promote THN prescription, we developed a noninterruptive decision support intervention that combined a detailed OD documentation template with a reminder to use the template that is automatically inserted into a provider's note by decision rules. We studied the impact of the combined intervention on THN prescribing in a longitudinal observational study.

METHODS

ED encounters involving an OD were reviewed before and after implementation of the reminder embedded in the physicians' note to use an advanced OD documentation template for changes in: (1) use of the template and (2) prescription of THN. Chi square tests and interrupted time series analyses were used to assess the impact. Usability and satisfaction were measured using the System Usability Scale (SUS) and the Net Promoter Score.

RESULTS

In 736 OD cases defined by International Classification of Disease version 10 diagnosis codes (247 prereminder and 489 postreminder), the documentation template was used in 0.0% and 21.3%, respectively (P < .0001). The sensitivity and specificity of the reminder for OD cases were 95.9% and 99.8%, respectively. Use of the documentation template led to twice the rate of prescribing of THN (25.7% vs 50.0%, P < .001). Of 19 providers responding to the survey, 74% of SUS responses were in the good-to-excellent range and 53% of providers were Net Promoters.

CONCLUSIONS

A noninterruptive decision support intervention was associated with higher THN prescribing in a pre-post study across a multiinstitution health system.

Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study

STUDY OBJECTIVE

We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders.

METHODS

This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects.

RESULTS

There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5).

CONCLUSION

A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.

Study protocol for a multisite randomized controlled trial of a peer navigator intervention for emergency department patients with nonfatal opioid overdose

BACKGROUND

Patients presenting to emergency departments (EDs) after a nonfatal opioid-involved overdose are at high risk for future overdose and death. Responding to this risk, the New York City (NYC) Department of Health and Mental Hygiene operates the Relay initiative, which dispatches trained peer "Wellness Advocates" to meet patients in the ED after a suspected opioid-involved overdose and follow them for up to 90 days to provide support, education, referrals to treatment, and other resources using a harm reduction framework.

METHODS

In this article, we describe the protocol for a multisite randomized controlled trial of Relay. Study participants are recruited from four NYC EDs and are randomized to receive the Relay intervention or site-directed care (the control arm). Outcomes are assessed through survey questionnaires conducted at 1-, 3-, and 6-months after the baseline visit, as well as through administrative health data. The primary outcome is the number of opioid-related adverse events, including any opioid-involved overdose or any other substance use-related ED visit, in the 12 months post-baseline. Secondary and exploratory outcomes will also be analyzed, as well as hypothesized mediators and moderators of Relay program effectiveness.

CONCLUSION

We present the protocol for a multisite randomized controlled trial of a peer-delivered OD prevention intervention in EDs. We describe how the study was designed to minimize disruption to routine ED operations, and how the study was implemented and adapted during the COVID-19 pandemic. This trial is registered with ClinicalTrials.gov [NCT04317053].

Evaluation of post-discharge engagement for emergency department patients with opioid use history who received telehealth recovery coaching services

BACKGROUND

In recent years, emergency departments (EDs) across the nation have implemented peer recovery coach (PRC) services to support patients who use opioids. The majority of such interventions discussed in the literature follow an in-person modality where PRCs engage patients directly at the ED bedside. However, the use of telehealth services in EDs is becoming more popular. These services connect PRCs with ED patients in real-time via secure communications technology, and very little is known about the service- and clinical-based outcomes with which they are associated. The current study sought to assess factors associated with successful post-discharge follow-up of patients with a history of opioid use who received PRC telehealth services while in the ED.

METHOD

Data come from records for 917 patients who engaged with a telehealth PRC one or more times (1208 total engagements) at 1 of 13 EDs within the same health system. A multilevel Poisson regression model was used to assess the degree to which variables predicted successful post-discharge follow-up, defined as the number of times a PRC successfully spoke with the patient each month after ED discharge.

RESULTS

At least one follow-up was successfully completed by a PRC for 23% of enrolled patients. Significant predictors of successful follow-up included patient employment at baseline (Incidence Rate Ratio [IRR]: 2.8, CI: 2.05-3.9), living in a rural area (IRR: 1.8, CI: 1.04-3.2), PRC provision of referrals (IRR: 1.7, CI: 1.2-2.2), number of ED encounters in the previous 365 days (IRR: 0.99, CI: 0.98-0.99), and duration of the initial PRC telehealth interaction (IRR: 0.87, CI: 0.85-0.88).

CONCLUSION

Given that relationship development is a key tool in the PRC profession, understanding successful follow-up associated with telehealth engagement has unique importance. The results have potential utility for planning and implementing peer telehealth services in EDs and other locations, which is needed for the development of the PRC profession and the likely expansion of peer telehealth services.

Development and initial findings from the Peer Recovery Coach (PRC) checklist: a new tool to assess the nature of peer recovery coaching service delivery

Background: Peer recovery coaching is recovery support service for Substance Use Disorder (SUD) that emphasizes shared lived experience and social support. Though a promising intervention for SUD, differences in the roles, responsibilities, and operationalization of peer recovery coaching across studies make objective implementation and evaluation of this service a challenge.Objective: This study sought to develop a tool to better guide and operationalize peer recovery coaching service delivery. This study describes the initial development, acceptability, feasibility, and validity of this tool: The PRC Checklist.Methods: The PRC Checklist was conceptualized and operationalized by drawing from social support theory and recovery capital research. The PRC Checklist was utilized by PRCs in a pilot randomized controlled trial to demonstrate feasibility and acceptability. To further validate the PRC Checklist, recovery coaches (N = 16; 56% female) were recruited to complete a survey about their responsibilities and their perspectives on the content and potential utility of the PRC Checklist.Results: The PRC checklist used in the pilot study delineates personalized from generalized support and tracks 25 specific activities across three domains of support (i.e. socioemotional, informational, and instrumental). PRCs in the pilot study were able to use the PRC Checklist in all in-person initial baseline encounters and 96.4% of follow-up encounters. Qualitative information collected during project meetings was generally positive but also identified potential limitations to its use. All PRCs surveyed reported that they agreed that the PRC Checklist was helpful, encompassed the services they provided, represented a good idea, provided meaningful information, and would be easy to use. All five of the most common activities PRCs engaged in were reflected in the PRC Checklist.Conclusion: Capturing both personal and generalized support provided by PRCs, this work suggests that the PRC Checklist captures key activities engaged in and is a helpful tool for use in healthcare settings.

Promoting the integration of peer support specialists into the healthcare team

ABSTRACT

The 21st Century Cures Act to address the opioid crisis spurred the expansion of the peer support specialist (PSS) workforce. Nurses are in key positions to promote the successful integration of the PSS into the healthcare team. This article describes the role of the PSS, including key functions that overlap with those of nurses and ways they can help mitigate stigma, which remains a significant barrier to patients' access to treatment.

Role of Peer Coaches in Digital Interventions for MOUD Initiation and Maintenance

Millions of Americans suffer from opioid use disorder (OUD) in the United States, resulting in thousands of deaths. The ongoing opioid crisis necessitates novel approaches to reduce the morbidity and mortality associated with misusing opioids. Studies using peer support models show success in engaging persons living with OUD in initiating treatment and decreasing relapse. Although most studies have focused on patients in clinical settings, community studies integrating peer community leaders also show promise. This viewpoint paper explores the use of peer coaches in online interventions in the community setting.

Exploring the consequences of food insecurity and harnessing the power of peer navigation and mHealth to reduce food insecurity and cardiometabolic comorbidities among persons with HIV: protocol for development and implementation trial of weCare/Secure

BACKGROUND

Food insecurity, or the lack of consistent access to nutritionally adequate and safe foods, effects up to 50% of people living with HIV (PWH) in the United States (US). PWH who are food insecure have lower antiretroviral adherence, are less likely to achieve viral suppression, and are at increased risk developing of serious illnesses, including cardiometabolic comorbidities. The objectives of this study are to better understand how food insecurity contributes to the development of cardiometabolic comorbidities among PWH and to test a novel bilingual peer navigation-mHealth intervention (weCare/Secure) designed to reduce these comorbidities in food-insecure PWH with prediabetes or Type 2 diabetes (T2DM).

METHODS

In Aim 1, we will recruit a longitudinal cohort of 1800 adult (≥18 years) PWH from our clinic-based population to determine the difference in the prevalence and incidence of cardiometabolic comorbidities between food-secure and food-insecure PWH. Food insecurity screening, indicators of cardiometabolic comorbidities, and other characteristics documented in the electronic health record (EHR) will be collected annually for up to 3 years from this cohort. In Aim 2, we will conduct a randomized controlled trial among a sample of food-insecure PWH who have prediabetes or T2DM to compare changes in insulin sensitivity over 6 months between participants in weCare/Secure and participants receiving usual care. In Aim 3, we will conduct semi-structured individual in-depth interviews to explore the effect of the intervention among intervention participants with varying insulin sensitivity outcomes.

TRIAL STATUS

Aim 1 (longitudinal cohort) recruitment began in May 2022 and is ongoing. Aim 2 (intervention) recruitment is planned for spring 2023 and is expected to be completed in spring 2024. Aim 3 (process evaluation) data collection will occur after sufficient completion of the 6-month assessment in Aim 2. Final results are anticipated in fall 2025.

CONCLUSIONS

This research seeks to advance our understanding of how food insecurity impacts the development of cardiometabolic comorbidities among PWH and how food insecurity interventions may alleviate relevant comorbidities. Given the growing interest among health systems in addressing food insecurity, if the intervention is found to be efficacious, it could be broadly disseminated across HIV clinical care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04943861 . Registered on June 29, 2021.

Public Perceptions of Community Pharmacy-Based Naloxone Services: A National Cross-Sectional Survey

Little is known about the general public's perceptions regarding community pharmacist-delivered naloxone services at the national level. Accordingly, the purpose of this study was to describe the US general public's awareness, knowledge, beliefs, comfort, perceived barriers, abilities, and communication preferences related to community pharmacy-based naloxone services. A national, online cross-sectional survey was conducted in September 2021 among US adults ≥18 years recruited via Amazon Mechanical Turk (MTurk). Primary outcome measures were assessed via 5-point Likert-type scales, including: (1) naloxone awareness and knowledge; (2) naloxone beliefs; (3) comfort with pharmacist-provided naloxone; (4) perceived barriers to pharmacy-based naloxone; (5) opioid overdose competencies, concerns, and readiness; and (6) preferred pharmacist-patient naloxone communication strategy. Analyses included descriptive statistics and logistic regression models to assess predictors of preferred communication strategies. Of 301 respondents, 82.1% were White, 48.8% female, and mean 43 years. Eighty-five percent were unaware of pharmacy-provided naloxone and mean [SD] knowledge score was low (29.3% [16.8]). Mean [SD] beliefs (3.78 [0.61]) and comfort (3.70 [0.54]) were positive, while perceived barriers were low/neutral (2.93 [0.78]). For communication, 54% preferred general advertisement, 32.9% universal offer, and 13.3% targeted offer. The odds of preferring a general advertisement or universal offer over a targeted offer increased with greater awareness (AOR:4.52; p = 0.003) and comfort (AOR:3.79; p = 0.003), and decreased with greater competence (AOR:0.35; p = 0.001). Although awareness and knowledge regarding community pharmacy-based naloxone services was low, beliefs and comfort were positive and perceived barriers were low/neutral. General or universal offers of naloxone were preferred over targeted approaches. Future studies should test the impact of communication strategies on naloxone uptake.

The Emergency Department Longitudinal Integrated Care (ED-LINC) intervention targeting opioid use disorder: A pilot randomized clinical trial

INTRODUCTION

Opioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).

METHODS

The research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n = 20) versus usual care control (n = 20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6 months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.

RESULTS

Overall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6 months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30 days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.

CONCLUSIONS

The ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations.

CLINICALTRIALS

gov NCT03699085.

Implementation Challenges and Recommendations for Employing Peer Support Workers in Emergency Departments to Support Patients Presenting after an Opioid-Related Overdose

The placement of a peer support workers (PSWs) in emergency departments (ED) is a promising practice for supporting persons with opioid use disorder who are presenting with an overdose or related medical condition. However, this practice is underutilized. The objective of this study was to identify the challenges of employing PSWs in the ED and provide a checklist to increase the likelihood of their successful integration and retention in this environment. Qualitative methods were used to collect data from nineteen key stakeholders who worked in hospital settings. Using a social-ecological model, themes were identified at the system, hospital, and individual levels. To support integration of PSWs and buy in for the ED team, our findings indicate a need for a planning phase that includes collaboration between leadership, ED staff, and PSWs. Specifically, planning should address four areas: (1) hiring a PSW that is a good fit for the fast-paced ED setting, (2) education of ED staff on the value and role of PSWs, (3) establishing workflow protocols, and (4) providing PSWs with training and appropriate supervision.

Integration of Life Care Specialists Into Orthopaedic Trauma Care to Improve Postoperative Outcomes: A Pilot Study

BACKGROUND

  AIM: This pilot study assessed the feasibility and impact of integrating a Life Care Specialist (LCS) into orthopaedic trauma care.

DESIGN

This was a prospective feasibility single group pilot study at a level 1 trauma center.

METHOD

The LCS is a paraprofessional behavior-based "pain coach" and delivered patient-centered opioid safety education, trained participants on nonpharmacologic pain management approaches, conducted opioid risk assessments, and coordinated care. Numeric Rating Scale pain scores were assessed on admission, at discharge, and at 2-week follow-up. Daily morphine milligram equivalents (MME) during hospitalization, opioid medication use at 2-weeks, and patient satisfaction were recorded. T test compared mean morphine milligram equivalents (MME) to historical orthopaedic trauma patient population's mean dosage at discharge from the study site. Generalized linear models assessed pain scores over time.

RESULTS

Twenty-two percent of 121 total participants met criteria for moderate to severe risk of opioid misuse at initial hospitalization. On average, 2.8 LCS pain management interventions were utilized, most frequently progressive muscle relaxation (80%) and sound therapy (48%). Mean inpatient MME/day was 40.5, which was significantly lower than mean historical MME/day of 49.7 (p < .001). Pain scores improved over time from admission to 2-weeks postoperatively (p < .001). Nearly all participants agreed that the LCS was helpful in managing pain (99%).

CONCLUSIONS

The findings indicate feasibility to integrate LCS into orthopaedic trauma care, evident by participant engagement and satisfaction, and that LCS serve as valuable resources to assist with pain management and opioid education.

Businesses in high drug use areas as potential sources of naloxone during overdose emergencies

INTRODUCTION

Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature.

METHODS

We surveyed business owners and employees (N = 149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone.

RESULTS

Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone.

CONCLUSIONS

Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.

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.

Opioid overdose survivors: Medications for opioid use disorder and risk of repeat overdose in Medicaid patients

BACKGROUND

Patients with medically-treated opioid overdose are at high risk for subsequent adverse outcomes, including repeat overdose. Understanding factors associated with repeat overdose can aid in optimizing post-overdose interventions.

METHODS

We conducted a longitudinal, retrospective cohort study using NJ Medicaid data from 2014 to 2019. Medicaid beneficiaries aged 12-64 with an index opioid overdose from 2015 to 2018 were followed for one year for subsequent overdose. Exposures included patient demographics; co-occurring medical, mental health, and substance use disorders; service and medication use in the 180 days preceding the index overdose; and MOUD following index overdose.

RESULTS

Of 4898 individuals meeting inclusion criteria, 19.6% had repeat opioid overdoses within one year. Index overdoses involving heroin/synthetic opioids were associated with higher repeat overdose risk than those involving prescription/other opioids only (HR = 1.44, 95% CI = 1.22-1.71). Risk was higher for males and those with baseline opioid use disorder diagnosis or ED visits. Only 21.7% received MOUD at any point in the year following overdose. MOUD was associated with a large decrease in repeat overdose risk among those with index overdose involving heroin/synthetic opioids (HR = 0.30, 95% CI = 0.20-0.46). Among those receiving MOUD at any point in follow-up, 10.5% (112/1065) experienced repeat overdose versus 22.1% (848/3833) for those without MOUD.

CONCLUSIONS

Repeat overdose was common among individuals with medically-treated opioid overdose. Risk factors for repeat overdose varied by type of opioid involved in index overdose, with differential implications for intervention. MOUD following index opioid overdose involving heroin/synthetic opioids was associated with reduced repeat overdose risk.

Peer Recovery Support Services Across the Continuum: In Community, Hospital, Corrections, and Treatment and Recovery Agency Settings - A Narrative Review

In this narrative review, we outline the literature describing the history, training, certification, and role of peer recovery support specialists working with people with substance use disorders at different stages of active use and recovery. We explore the impact of peer recovery support specialists serving people in various settings, including the community, hospitals and emergency departments, jails and prisons, and treatment and recovery agencies; and describes considerations for future expansion of peer recovery support services, including supervision needs, compassion fatigue and burnout, and scope of practice. Finally, we make recommendations to support the broad implementation of peer recovery support services as a sustainable, cohesive, and replicable component of harm reduction and addiction services. We also make recommendations for research to continue to evaluate peer recovery support specialist interventions across settings and outcomes.

The Impact of a Peer-Navigator Program on Naloxone Distribution and Buprenorphine Utilization in the Emergency Department

Objectives: In recent years many emergency departments (EDs) have adopted interventions to help patients with opioid use disorder (OUD), particularly buprenorphine initiation and ED-based peer recovery support. There are limited data on the impact of peer navigators on provider naloxone kit distribution and buprenorphine utilization. We aimed to examine the impact of a peer recovery program on naloxone kit distribution and buprenorphine administration. Methods: This was a retrospective study analyzing the change in naloxone kits distributed as well as buprenorphine administrations. Data on naloxone kit and buprenorphine administrations was generated every month between November 2017 and February 2021. Time periods were as follows: implementation of guidelines for buprenorphine and naloxone kits, initiation of the navigator program, and first wave of COVID-19. Numbers of naloxone kits distributed and buprenorphine administrations per month were computed. Results: Between November 2017 and December 2020, there was a significant increase overtime among the 238 naloxone kits distributed (p < 0.0001). Between implementation of guidelines and introduction of peer navigators, there were 49 kits distributed, compared to an increase overtime among 235 kits when the navigator program began (p = 0.0001). There was also a significant increase overtime among 1797 administrations of buprenorphine (p < 0.0001). Administrations increased by 22.4% after implementation of the navigator program-a total of 787 compared to 643 post guideline (p = 0.007). Conclusion: Peer recovery support programs for patients with OUD can have an impact on administration of naloxone kits and buprenorphine. Future studies should determine whether these programs can cause a long-term culture change in the ED.

Racial disparities in linkage to care among patients with substance use disorders

OBJECTIVE

Peer support specialists (PSSs) can effectively link patients with substance use disorders (SUD) to treatment. These specialists can engage patients in treatment after emergency department (ED) visits or inpatient hospitalization, crucial points in time when these patients have contact with the health care system. We describe success of PSSs in recruiting SUD patients into treatment, with attention to racial disparities in linkage to care.

METHODS

This is a retrospective, observational cohort study performed at an urban, academic medical center. Patients with SUD who indicated interest in pursuing addiction treatment were linked with PSSs by staff at discharge from the ED or inpatient hospitalization. PSSs then transported willing patients to a partnering addiction treatment facility. The treatment facility provided data on successful linkage to care, defined as enrolling in an inpatient or outpatient treatment program. Our primary outcome was successful enrollment in treatment after engagement. The secondary outcome was patients' agreement to transport to the treatment facility after engagement by a PSS. We performed subgroup analysis of patients by self-described race.

RESULTS

A total of 785 patients met inclusion criteria for the study: 168 Black patients and 617 White patients. White patients were more likely than Black patients to be enrolled in treatment by PSSs (adjusted odds ratio [aOR; 95% confidence interval {CI}] = 1.61 [1.11 to 2.34]), after adjusting for the effects of age, sex, insurance, and marital status, p = 0.012. We found no statistically significant differences between races in agreeing to be transported for the total sample or inpatient subjects. For ED patients, White individuals were more likely to be transported to treatment compared to Black or African American patients (adjusted odds ratio [aOR; 95% confidence interval {CI}] = 1.50 [1.00 to 2.23]).

CONCLUSION

Our results provide evidence of racial disparities in successful linkage to care by PSSs among patients with SUD. Fewer Black patients were successfully linked to care when approached in the ED, where the majority of these patients were engaged, and after controlling age, sex, insurance, and marital status. Future research should study factors that drive these disparities, and how to successfully link all patients to care.

Effectiveness of peer recovery support services on stages of the opioid use disorder treatment cascade: A systematic review

BACKGROUND

Peer recovery support services (PRSS) have been increasingly incorporated during the recovery process for opioid use disorder (OUD), yet little is known about the effects of PRSS on clinical outcomes of individuals who misuse opioids. This study systematically synthesized existing literature reporting the effectiveness of PRSS interventions on stages of the OUD treatment cascade.

METHODS

A search conducted on five databases identified studies from database inception to January 26th 2021 that evaluated the effects of PRSS on PRSS engagement, medication for OUD (MOUD) initiation, MOUD retention, opioid and non-opioid misuse, and remission. Characteristics of PRSS interventions, study design, and clinical outcomes were extracted. Methodological quality was assessed with the quality assessment tool for quantitative studies by the Effective Public Health Practice Project.

RESULTS

Of 123 titles, 22 were subjected to full-text review and 12 ultimately met inclusion criteria. Only two studies were randomized control trials, half compared the outcomes of PRSS participants to those of a counterfactual group. Most PRSS were unstandardized and broadly described, involving linkage to treatment (91.7%) or follow-up support (91.7%). MOUD initiation was reported the most often (66.7%), followed by PRSS engagement (33.3%) and opioid use (25.0%). No studies reported findings for MOUD retention or remission. Findings for available outcomes were inconsistent and difficult to compare due to the heterogeneity of PRSS interventions and methodological limitations.

CONCLUSION

Effectiveness of PRSS interventions on stages of the OUD treatment cascade remain inconclusive. Additional research is necessary before supporting the implementation of PRSS on a broad scale.

Does naloxone provision lead to increased substance use? A systematic review to assess if there is evidence of a 'moral hazard' associated with naloxone supply

BACKGROUND

Take home naloxone (THN) programs have been rapidly upscaled in response to increasing opioid-related mortality. One often cited concern is that naloxone provision could be associated with increased opioid use, due to the availability of naloxone to reverse opioid overdose. We conducted a systematic review to determine whether THN provision is associated with changes in substance use by participants enrolled in THN programs.

METHODS

We conducted a systematic review of the literature to assess changes in heroin or other substance use by people who use opioids following THN provision.

RESULTS

Seven studies with 2578 participants were included. Of the seven studies, there were two quasi-experimental studies and five cohort studies. Based on the Joanna Briggs Institute quality assessment, four studies were of moderate quality and three studies were of high quality. Of the five studies that reported on the primary outcome of heroin use, no study found evidence of increased heroin use across the study population. Five studies reported on other substance use (benzodiazepines, alcohol, cocaine, amphetamine, cannabis, prescription opioids), none of which found evidence of an increase in other substance use associated with THN provision. Four studies reported on changes in overdose frequency following THN provision: three studies reporting no change, and one study of people prescribed opioids finding a reduction in opioid-related emergency department attendances for participants who received naloxone.

CONCLUSION

We found no evidence that THN provision was associated with increased opioid use or overdose. Concerns that THN supply may lead to increased substance use were not supported by data from reviewed studies.

The mobile emergency recovery intervention trial (MERIT): Protocol for a 3-year mixed methods observational study of mobile recovery outreach teams in Nevada's emergency departments

Background

The Substance Abuse and Mental Health Administration awarded State Targeted Response grants to support states’ efforts to address the opioid epidemic. In Nevada, one component of this grant was mobile recovery outreach teams (MROTs) that utilized peer recovery support specialists to provide care for qualifying patients in emergency departments (EDs). The Mobile Emergency Recovery Intervention Trial (MERIT) is a mixed methods study to assess the feasibility/acceptability and effectiveness of the MROT intervention. This protocol mainly describes the R33 research activities and outcomes. The full protocol can be found protocols.io.

Methods

Data will be derived from state-level data sets containing de-identified emergency department visits, substance use disorder treatment records, and mortality files; in-person mixed methods interviews; participant observation; and self-report process evaluation forms. Primary outcomes include Medication Assisted Treatment (MAT) initiation and non-fatal overdose; secondary outcomes include MAT retention and fatal overdose. Quantitative hypotheses will be tested using generalized linear mixed effects models, Bayesian hierarchical models, and marginal Cox models. Qualitative interview data will be analyzed using an inductive thematic analysis procedure.

Discussion

The geography of emergency department-based HIV testing in South Africa: Can patients link to care?

BACKGROUND

Emergency Departments (EDs) can serve as clinical sites for identification of new HIV infections and their entry into care. We examined if HIV-positive patients who present to EDs in South Africa are able to successfully link to care.

METHODS

We conducted a one-year longitudinal prospective cohort study in four hospitals across the Eastern Cape, South Africa, with participants followed between July 2016 and July 2018. All adult, non-critical patients presenting to the ED were systematically approached, asked about their HIV status, and, if unknown, offered a point-of-care (POC) HIV test. All HIV-positive patients were further consented to participate in a follow-up study to assess subsequent linkage to care and distance from "home" to ED. Linkage to care was defined as self-reported linkage (telephonic) or evidence of repeated CD4/viral load testing in the National Health Laboratory System (NHLS) at either the 6- or 12-months post index ED visit.

FINDINGS

A total of 983 HIV-positive patients consented to participate in the study. In the 12 months following their ED visit, 34·1% of patients demonstrated linkage to care (335/983), 23·8% did not link to care (234/983), and 42·1% (414/983) were lost to follow-up. Though not statistically significant, a high percentage of young men (27/50, 54%) and those presenting with a trauma-related complaints (100/205, 48.8%) did not link to care. A considerable proportion of patients (105/454, 23·2%,) resided 50 or more kilometers from their index ED sites, though there was not a significant difference in linkage to care rate between those who lived closer or further from the ED.

INTERPRETATION

We have shown that strategies to improve linkage to care from the ED should consider the high rates of poor linkage among young men and those presenting to the ED with trauma. Furthermore, innovative linkage to care solutions will need to account for the unique geographical consideration of this population, given that many ED patients will need to continue care at a site distant from the diagnosis site.

FUNDING

This research was supported by the South African Medical Research Council, the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Johns Hopkins Center for Global Health.

A Systematic Review of the Roles and Contributions of Peer Providers in the Behavioral Health Workforce

CONTEXT

Peer providers with lived experiences of mental health and substance use are a growing component of the workforce responsible for the prevention and treatment of behavioral health disorders. This systematic literature review aims to better define the roles of peers and their unique contributions to behavioral health care.

EVIDENCE ACQUISITION

Researchers searched MEDLINE, CINAHL Complete, PsycINFO, Cochrane Central, and Scopus databases for studies published between January 1, 2013 and April 3, 2020. Studies were included if they (1) were experimental or observational studies, (2) included an adult population of people with a behavioral health disorder, and (3) used paid peer providers in addition to traditional behavioral health services. Researchers extracted sample demographics, intervention characteristics, outcome data, and significant associations from studies that met inclusion criteria and assessed the trends in these data in May 2020.

EVIDENCE SYNTHESIS

A total of 23 articles assessing peer-provided services were included. Peers were employed most frequently in mental healthcare roles in the Department of Veterans Affairs, hospital, and community health facilities. A total of 14 studies observed significant clinical improvements in participants' social functioning, quality of life, patient activation, and behavioral health. A majority of studies involved the supervision of peers and required peers to have completed training in service delivery.

CONCLUSIONS

Peers are effective providers of behavioral health treatment and relapse prevention services who encourage recovery through resilience building, empowerment, and self-advocacy. There remains a need for more evidence-based interventions on the efficacy of peers in substance use disorder treatment and the impact of formalized certification and training opportunities.

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.

Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

STUDY OBJECTIVE

We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment.

METHODS

A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation.

RESULTS

We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

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.

Targeting the Barriers in the Substance Use Disorder Continuum of Care With Peer Recovery Support

Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.

Linking criminal justice-involved individuals to HIV, Hepatitis C, and opioid use disorder prevention and treatment services upon release to the community: Progress, gaps, and future directions

Improving HIV and Hepatitis C Virus (HCV) management among people involved in the criminal justice (CJ) system who use drugs, in particular those with opioid use disorder (OUD), requires effective approaches to screening, linkage, and adherence to integrated prevention and treatment services across correctional and community agencies and providers. This manuscript reviews the literature to explore gaps in HIV, Hepatitis C, and OUD prevention, treatment, and delivery cascades of care for persons involved in the CJ system. Specifically, we compare two models of linkage to prevention and treatment services: Peer/Patient Navigation (PN) wherein the PN links CJ-involved individuals to community-based infectious disease (ID) and substance use prevention and treatment services, and Mobile Health Units (MHU) wherein individuals are linked to a MHU within their community that provides integrated ID and substance use prevention and treatment services. The most notable finding is a gap in the literature, with few to no comparisons of models linking individuals recently released from the CJ system to integrated HIV, Hepatitis C, and OUD prevention and treatment and other harm reduction services. Further, few published studies address the geographical distinctions that affect service implementation and their effects on these substance use, ID and harm reduction care cascades. This manuscript makes specific recommendations to fill this gap through a detailed evaluation of PN and MHU linkage models to co-located and integrated HIV, Hepatitis C, and OUD prevention and treatment services across different communities within the U.S.

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

OBJECTIVE

Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence-based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post-opioid overdose period.

METHODS

We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural).

RESULTS

The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self-reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs.

CONCLUSIONS

Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED-based research evaluating a patient-oriented approach to engage patients after opioid overdose.

Implementation of peer recovery coach services for opioid overdose patients in emergency departments in Indiana: findings from an informal learning collaborative of stakeholders

The Recovery Coach and Peer Support Initiative (RCPSI) in Indiana focused on implementing peer recovery coaches (PRCs) to engage opioid overdose patients in emergency department (ED) settings and promote entry into recovery services. State workers and researchers organized an informal learning collaborative primarily through teleconference meetings with representatives of 11 health service vendors to support implementation. This study presents qualitative analysis of the teleconference meeting discussions that guided RCPSI implementation to display how the informal learning collaborative functioned to support implementation. This informal learning collaborative model can be applied in similar situations where there is limited guidance available for a practice being implemented by multidisciplinary teams. Authors conducted a thematic analysis of data from 32 stakeholder teleconference meetings held between February 2018 and April 2020. The analysis explored the function of these collaborative teleconferences for stakeholders. Major themes representing functions of the meetings for stakeholders include: social networking; executing the implementation plan; identifying and addressing barriers and facilitators; educating on peer recovery services and target population; and working through data collection. During the last 2 months of meetings, stakeholders discussed how the COVID-19 pandemic created multiple barriers but increased use of telehealth for recovery services. Teleconference meetings served as the main component of an informal learning collaborative for the RCPSI through which the vendor representatives could speak with each other and with organizers as they implemented the use of PRCs in EDs.

Facilitators and barriers to post-overdose service delivery in Rhode Island emergency departments: A qualitative evaluation

BACKGROUND

Emergency departments (EDs) in the US have increasingly incorporated interventions that seek to reduce opioid-related morbidity and mortality. However, many of these interventions are underutilized. This study examined ED provider-identified barriers and facilitators to policy-prescribed service provision for patients treated for an opioid overdose in Rhode Island EDs, and opportunities to improve care delivery.

METHODS

Semi-structured qualitative interviews were conducted with 55 ED providers (management and clinical staff) across Rhode Island EDs from November 2019 to July 2020. Thematic analysis of interviews focused on gaps and best practices in post-overdose care delivery, including social and structural factors driving access to, and uptake of, services.

RESULTS

Participants highlighted how automatic service delivery (opt out vs. opt in) and the integration of peer-based services enhanced post-overdose service provision. However, social and structural factors (e.g. insurance barriers, limited outpatient treatment resources) and gaps in provider knowledge of medications for opioid use disorder created barriers to care. Addressing long ED wait times and establishing dedicated care teams for patients following an overdose were seen as critical to improving ED service delivery.

CONCLUSION

Our findings suggest that post-overdose service delivery within EDs is a useful approach for connecting patients to services, particularly when peer support specialists are involved. However, standardizing service delivery approaches and improving provider education of harm reduction services must be prioritized alongside state-level policy changes to improve access to care for ED patients.

Adaptations to Indiana's 21st Century Cures-funded recovery coaching initiative in the wake of COVID-19

This brief commentary discusses how provider organizations from Indiana's Recovery Coach and Peer Support Initiative (RCPSI) adapted their practices in response to the COVID-19 pandemic and associated restrictions. The RCPSI, which is funded through the 21st Century Cures Act, placed peer recovery coaches (PRCs) in emergency departments (EDs) to link opioid overdose patients to medication for opioid use disorder. This commentary discusses how COVID-19 restrictions increased use of telehealth to replace in-person PRC contacts with patients, affected the timing of initial PRC contacts with patients, and led to allowances for Medicaid billing of recovery coach support sessions conducted via telehealth. Future research should further determine the effects of these changes on PRC services in the ED.