(106) Naloxone and Medication for Opioid Use Disorder in US Emergency Departments

Background & Introduction: The emergency department (ED) is an important location for treatment for opioid use disorder (OUD) and harm reduction. The American College of Emergency Physicians (ACEP) produced guidelines recommending 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”(1). Several studies document the benefits of starting medication for OUD (MOUD) from the ED are well-documented, including a randomized controlled trial that found that 30-day retention in treatment doubled when patients with OUD were provided buprenorphine and rapid follow-up compared to those provided only referral to treatment (78% vs. 37%) (2). Likewise, naloxone is a fundamental harm reduction tool, and the ED is promising location for providing naloxone and naloxone distribution programs are feasible (3). The goal of our study is to assess the current practices surrounding OUD, specifically provision of naloxone and MOUD, in a large sample of EDs participating in a quality improvement initiative. The secondary aim was to determine if there are patient- and department-level characteristics associated with the primary outcomes.

Methods: Data were obtained from EDs that participate in the American College of Emergency Physicians’ Emergency Quality Network (E-QUAL) substance use disorder program, a national practice-based quality improvement initiative. ED sites abstracted key data elements from a random sample of adult patient visits with diagnosis codes suggestive of opioid overdose (selected from ICD-10 T.40) or opioid use disorder (selected from ICD-10 F.11). Data were captured in March and October, 2023. Only visits in which the patient was discharged from the ED were included. Collected data included demographics, if the ED visit was for opioid overdose, if naloxone was prescribed or dispensed, and if MOUD was administered or prescribed. Site specific information (e.g. annual visit volume, rural/critical access hospital status) was also collected. Next, two multivariable analyses were performed: one was to determine patient- and department-level characteristics associated with being prescribed or dispensed naloxone, and the other was to determine characteristics associated with being prescribed or dispensed MOUD. For the analysis of MOUD, patients documented as already being on MOUD were excluded.

Results: There were 6,749 included visits reported from 300 unique EDs. Most EDs saw fewer than 20,000 visits per year (n=139, 54.1%), and many were rural or rural/critical access (n=134, 44.7%). Patient age was mean 41.1 (SD 14.3) years. Most were male (60.7%, n=4,097). Race was 3,113 (46.1%) White, 785 (11.6%) Black, 19 (0.3%) Asian or Pacific Islander, and 17 (0.3%) American Indian/Alaska Native. 2,816 (41.7%) were “other”, “unknown” or missing. Ethnicity was 1,256 (18.6%) non-Hispanic, 81 (1.2%) Hispanic, and the remainder “unknown”/missing. Insurance was: 3,225 (47.8%) Medicaid, 1,306 (19.4%) self-pay/uninsured, 1,146 (17.0%) Medicare, 985 (14.6%) private/commercial, and 87 (1.3%) other/unknown.

Naloxone was either dispensed or prescribed in 1,874 (27.8%) of visits. About half of visits (n=3,195, 47.3%) were for opioid overdose. In these cases, naloxone was dispensed or prescribed in 1,410 (44.1%) visits. There were 752 visits (11.1%) in which it was reported that the patient was already taking MOUD. Excluding those visits, MOUD was either administered in the ED or prescribed at discharge 438 times, representing 7.3% of potentially eligible visits.

The following characteristics were associated with provision of naloxone: older patients (65-97 years) were less likely than patients aged 25-49 (adjusted odds ratio (aOR) 0.62, [95% confidence interval 0.44-0.88]). Males were more likely than females (aOR 1.34 [1.17-1.53]), and Black patients were more likely than White patients (aOR 1.49, [1.21-1.82]). Compared with those who have private/commercial insurance, those with Medicaid (aOR 1.63, [1.34-2.00]) and self-pay/uninsured (aOR 1.33, [1.06-1.67]) were more likely to receive naloxone. The greatest predictor of naloxone provision was an ED visit for overdose (aOR 6.09, [5.28-7.02]). EDs with >20% non-English speaking patients (aOR 0.66, [0.55-0.80]) and rural/critical access hospitals (0.60, [0.51-0.69]) were less associated with naloxone.

The following characteristics were associated with provision of MOUD to patients who were not already reported as taking it: patients aged 50-64 years were less likely compared to patients aged 25-49 (aOR 0.48, [0.32-0.72]). Males were more likely than females (aOR 1.45, [1.12-1.86]), and Black patients were more likely than White patients (aOR 0.60, 95% [0.39-0.93]). Visits by patients with Medicaid were more likely to have provision of MOUD compared with those with private/commercial insurance (aOR 1.46, [1.02-2.09]). Visits for overdose were more likely to result in prevision of MOUD (aOR 8.15, [5.88-11.29]). EDs with >20% non-English speaking patients (aOR 0.68, [0.49-0.95]) and those that are rural/critical access (aOR 0.49, [0.37-0.66]) were less likely to provide MOUD.

Conclusion & Discussion: In this large sample of visits for OUD and overdose from over 300 community EDs across the US, MOUD treatment is suboptimal. Just over a quarter of patients with visits related to opioids were prescribed or dispensed naloxone, although the number was higher (44.1%) when the visit was related to overdose. Likewise, administration or prescription of MOUD to patients not already taking it was also low (7.3%), again indicating an area for improvement.

Characteristics associated with receiving naloxone and MOUD included being male, being Black compared to White, and having Medicaid compared to private/commercial insurance. The race finding differs from research that found Black patients were less likely to receive MOUD (4), although this result may also reflect high missingness of our race variable and should be interpreted with caution. As naloxone and MOUD were more likely to be provided when the visit was for overdose, more work is needed to remind clinicians that this applies to all at-risk patients, and not just those presenting after overdose. Finally, EDs that saw larger proportions of patients who did not speak English, and those that are rural/critical access, may benefit from targeted interventions to improve access to these potentially life-saving treatments.

References: 1) Hawk, K., Hoppe, J., Ketcham, E., LaPietra, A., Moulin, A., Nelson, L., Schwarz, E., Shahid, S., Stader, D., Wilson, M. P., & D'Onofrio, G. (2021). Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Annals of emergency medicine, 78(3), 434–442. https://doi.org/10.1016/j.annemergmed.2021.04.023

2) D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16), 1636–1644. https://doi.org/10.1001/jama.2015.3474

3) Bennett, A. S., & Elliott, L. (2021). Naloxone's role in the national opioid crisis-past struggles, current efforts, and future opportunities. Translational research: the journal of laboratory and clinical medicine, 234, 43–57. https://doi.org/10.1016/j.trsl.2021.03.001

4) Barnett, M. L., Meara, E., Lewinson, T., Hardy, B., Chyn, D., Onsando, M., Huskamp, H. A., Mehrotra, A., & Morden, N. E. (2023). Racial Inequality in Receipt of Medications for Opioid Use Disorder. The New England journal of medicine, 388(19), 1779–1789. https://doi.org/10.1056/NEJMsa2212412