Among commercially insured adults, only 16% who suffered a nonfatal opioid overdose sought follow-up treatment for opioid use disorder. Even then, age, sex, and race/ethnicity disparities in obtaining such care exist, according to results published in JAMA Network Open. Patients who received pre-overdose treatment for opioid use disorder, however, were the most likely to obtain follow-up care after overdose.
“Each year, the emergency department (ED) provides care for an increasing number of patients who present with opioid overdose as well as medical complications of opioid use disorder (OUD). The ED serves as an essential touchpoint for patients seeking care for withdrawal and addiction. A key strategy in secondary prevention of opioid overdose deaths is the engagement of patients with OUD in treatment following discharge,” noted Austin S. Kilaru, MD, MSHP, of the Center for Emergency Care Policy and Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, and fellow researchers.
Indeed, timely referral and initiation of follow-up treatment after such events is associated with reduced mortality.
“However, few patients successfully transition to treatment following nonfatal overdose,” noted Kilaru and colleagues.
To assess the incidence of follow-up treatment in the 90 days following ED discharge after a nonfatal opioid overdose, these researchers conducted this retrospective study using an administrative claims database from a large commercial US insurer to identify 6,451 adult patients (mean age: 45.0 years; 50.6% women; 72.5% non-Hispanic white) who had been discharged from the ER after an opioid overdose—meaning that they had not overdosed in the preceding 90 days.
Heroin overdose occurred in 1,896 (29.4%) patients, and prescription opioid overdose in 4,555 (70.6%). In the 3 months preceding overdose, only 10.6% had received treatment for their opioid use disorder.
They also assessed patient characteristics that were associated with timely follow-up care, as previous studies have suggested that there are significant disparities based on race, sex, and geography that are possibly caused by differences in health insurance coverage.
Only 16% of patients (95% CI: 15.7%-17.5%) had gone for follow-up treatment within 90 days after their overdose, 29.7% of whom did so within 7 or less days after the overdose. Even more striking was that the finding that among the 5,769 patients who did not receive any treatment services for opioid use disorder before the index overdose, the number who obtained follow-up treatment dropped to 11.1% (95% CI: 10.3%-12.0%), which was significantly lower than among the 682 patients who did receive pre-overdose treatment (62.5%; 95% CI: 58.7%-66.1%).
And, upon their adjusted analysis of those patients who did not receive treatment before overdosing, Kilaru and colleagues found that black patients were 50% less likely to obtain follow-up compared with non-Hispanic white patients (ARD: −5.9%; 95% CI: −8.6% to −3.6%). Also, less likely to obtain follow-up were women (ARD: −1.7%; 95% CI: −3.3% to −0.5%) and Hispanic patients (ARD: −5.9%; 95% CI: −8.6% to −3.6%).
Those experiencing prescription opioid overdose were less likely to go for follow-up compared with those experiencing heroin overdose (ARD: −8.8%; 95% CI: −11.2% to −6.5%). Interestingly, those who had received recent treatment for anxiety were more likely to go for follow-up, including patients who had a treatment encounter for anxiety (ARD: 3.4%; 95% CI: 1.1%-5.8%) and those who received a prescription for a benzodiazepine (ARD: 2.8%; 95% CI: 0.7%-5.0%).
Finally, Kilaru and colleagues found that for as patients got older, the likelihood of obtaining follow-up after an overdose decreased. In fact, for each additional year of age, patients were 0.2% less likely to go for follow-up (95% CI: −0.3% to −0.1%).
Limitations of the study include researchers’ inability to account for patients who paid out-of-pocket for treatment for opioid use disorder, exclusion of patients treated with methadone maintenance therapy, failure to account for mortality following the index overdose, and the inability to determine the reasons patients did or did not obtain follow-up treatment. Finally, noted Kilaru and fellow researchers, the probable inclusion of patients who may not have had opioid use disorder in this cohort may account for the differences in follow-up treatments between patients with heroin and prescription opioid overdoses.
In seeking to understand why so few of these patients obtain follow-up treatment, Elizabeth M. Schoenfeld, MD, MS, of the University of Massachusetts Medical School-Baystate Medical Center, Springfield, MA, and colleagues, noted the many barriers that exist for the implementation of medication for opioid use disorder (MOUD), including individual-level barriers.
“For both clinicians and patients, many individual-level barriers to MOUD implementation exist, including lack of knowledge, beliefs about MOUD, and self-efficacy. Unlike aspirin therapy for [acute myocardial infarction], which has been in clinical guidelines for decades, clinicians may lack knowledge about the effectiveness of MOUD, how to screen patients, and how to initiate treatment,” they wrote in an accompanying editorial. “Clinicians may also lack self-efficacy; that is, although they may believe the evidence regarding MOUD, they may doubt their ability to start MOUD therapy for a patient. Likewise, patients may not believe in their own ability to ’get clean.’”
Other barriers include structural, logistic, and economic factors, as well as the complexity of providing MOUD intervention faced by clinicians and the complexity of receiving such care for patients.
Schoenfeld and colleagues called for future research to address these barriers to implementation.
“The low prevalence of treatment after overdose highlighted by Kilaru et al means that, at the height of the opioid epidemic, we as a health care community are missing opportunities to save lives. Increasing knowledge, reducing stigma, addressing logistics, decreasing regulations, and providing incentives to treat patients with [opioid use disorder] must all be considered if we are to truly make a difference,” they concluded.
Among commercially insured patients, timely treatment for opioid use disorder after an overdose is low, with only 16% obtaining follow-up care.
Age, sex, and racial disparities exist in obtaining follow-up treatment after nonfatal opioid overdoses.
E.C. Meszaros, Contributing Writer, BreakingMED™
Kilaru reported no conflicts of interest.
This study was supported by a pilot grant from the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
Schoenfeld receives support from the Agency for Health Research and Quality.
Cat ID: 144
Topic ID: 87,144,730,192,144