161 The Impact of Statewide Emergency Department Opioid Overdose Treatment Standards on Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

Abstract

Determine the impact of Rhode Island (RI)’s emergency department (ED) opioid use disorder (OUD) treatment standards, the Levels of Care for Rhode Island EDs and Hospitals for Treating Overdose and OUD (Levels of Care), on ED provision of take-home naloxone, behavioral counseling, and referral to treatment after certification of level of care policy implementation. Data from the Rhode Island Department of Health’s 48-hour ED opioid overdose reporting system were analyzed from 2016 to 2018 to determine changes in services provision after hospital level of care certification for patients 18 years of age and older discharged from a RI ED after being treated for a non-fatal opioid overdose. The primary outcomes were offering and provision of: 1) take-home naloxone; 2) ED behavioral counseling; 3) referral to OUD treatment. Changes in services provision before and after hospital certification were compared using a chi-square test and using predicted probabilities from a multivariable GEE model with a binomial outcome, logit link, and variance clustered within hospitals. Sub-analyses were conducted looking at changes after certification at facilities certified as Level 3, the minimum standard of care, and those certified as Level 1, which provide the minimum standard of care as well as access to comprehensive addiction treatment services and medication for addiction treatment. There were 2,049 ED opioid overdose visits before hospital level of care certification and 1,338 after. Six hospitals were certified as Level 1; four were certified as Level 3. The majority of patients were male (71%), 25-44 years old (61%), and white (78%). After hospital certification, patients were more likely to be offered (60% vs 82%, p<0.001) and given (41% vs 51%, p<0.001) take-home naloxone. Overall, counseling offers increased (58% vs 85%, p<0.001), but receipt of counseling did not change (35% vs 33%, p=0.137). After adjusting for age, sex, naloxone administration prior to ED arrival, previous overdose ED visit in the past year, calendar time, season, and within-hospital clustering, there was no significant change in offering or receipt of take-home naloxone after hospital certification. In adjusted estimates, more patients were offered counseling after certification at Level 3 (24% vs. 77%, p<0.001) hospitals, but there was no significant change at Level 1 hospitals (42% vs. 72%, p=0.139). There was no significant change in receiving counseling; however, there was an increase in referral to treatment for both Level 1 (15% vs. 21%, p=0.044) and Level 3 (27% vs. 43%, p=0.004) hospitals after certification. The RI Levels of Care are the first state-wide adopted treatment standards for opioid overdose and OUD. Hospital certification is associated with increased provision of take-home naloxone, offering of counseling at Level 3 hospitals, and referral to treatment at all hospitals. Future investigations are needed to better characterize implementation barriers and evaluate policy impact on patient outcomes.