Overdose Emergency Department Research Articles

Community-Based Medications First for Opioid Use Disorder - Care Utilization and Mortality Outcomes.

A large treatment gap exists for people who could benefit from medications for opioid use disorder (MOUD). People OUD accessing services in harm reduction and community-based organizations often have difficulty engaging in MOUD at opioid treatment programs and traditional health care settings. We conducted a study to test the impacts of a community-based medications first model of care in six Washington (WA) State communities that provided drop-in MOUD access. Participants included people newly prescribed MOUD. Settings included harm reduction and homeless services programs. A prospective cohort analysis tested the impacts of the intervention on MOUD and care utilization. Intervention impacts on mortality were tested via a synthetic comparison group analysis matching on demographics, MOUD history, and geography using WA State agency administrative data. 825 people were enrolled in the study of whom 813 were matched to state records for care utilization and outcomes. Cohort analyses indicated significant increases for days' supply of buprenorphine, months with any MOUD, and months with any buprenorphine for people previously on buprenorphine (all results p<0.05). Months with an emergency department overdose did not change. Months with an inpatient hospital stay increased (p<0.05). The annual death rate in the first year for the intervention group was 0.45% (3 out of 664) versus 2.2% (222 out of 9893) in the comparison group in the 12 months; a relative risk of 0.323 (95% CI 0.11-0.94). Findings indicated a significant increase in MOUD for the intervention group and a lower mortality rate relative to the comparison group. The COVID-19 epidemic and rapid increase in non-pharmaceutical-fentanyl may have lessened the intervention impact as measured in the cohort analysis. Study findings support expanding access to a third model of low barrier MOUD care alongside opioid treatment programs and traditional health care settings.

Trends in recurrent overdose and treatment initiation following emergency department visits for opioid overdose between 2016 and 2021

BackgroundOverdose remains a pressing public health concern in the United States, particularly with the emergence of fentanyl and other potent synthetic opioids in the drug supply. We evaluated trends in recurrent overdose and opioid use disorder (OUD) treatment initiation following emergency department (ED) visits for opioid overdose to inform response efforts. MethodsThis retrospective cohort study used electronic health record and statewide administrative data from Rhode Island residents who visited EDs for opioid overdose between July 1, 2016, and June 30, 2021, a period with fentanyl predominance in the local drug supply. The primary outcome was recurrent overdose in the 365 days following the initial ED visit. OUD treatment initiation within 180 days following the initial ED visit was considered as a secondary outcome. Trends in study outcomes were summarized by year of the initial ED visit. ResultsAmong 1745 patients attending EDs for opioid overdose, 20 % (n=352) experienced a recurrent overdose within 365 days, and this percentage was similar by year (p=0.12). Among patients who experienced any recurrent overdose, the median time to first recurrent overdose was 88 days (interquartile range=23–208), with 85 % (n=299/352) being non-fatal. Among patients not engaged in OUD treatment at their initial ED visit, 33 % (n=448/1370) initiated treatment within 180 days; this was similar by year (p=0.98). ConclusionsFollowing ED visits for opioid overdose in Rhode Island from 2016–2021, the one-year risk of recurrent overdose and six-month treatment initiation rate remained stable over time. Innovative prevention strategies and improved treatment access are needed.

Trends in pediatric prescription-opioid overdoses in U.S. emergency departments from 2008-2020: An epidemiologic study of pediatric opioid overdose ED visits.

Opioid overdose was declared a public health emergency in the United States, but much of the focus has been on adults. Child and adolescent exposure and access to unused prescription-opioid medications is a big concern. More research is needed on the trend of pediatric (age 0-17) prescription-opioid overdose emergency department (ED) visits in the United States, particularly during the COVID-19 pandemic year. This retrospective epidemiological study used the 2008-2020 Nationwide Emergency Department Sample to provide a national estimate of ED visits related to prescription-opioid overdose. Inclusion criteria were 0-17-year-old patients treated at the ED due to prescription-opioid overdose. Eligible visits were identified if their medical records included any administrative billing codes for prescription-opioid overdose. National estimates were broken down by age groups, sex, geographic region, primary payer, median household income by zip code, ED disposition, and hospital location/teaching status. Incidence rate per 100,000 U.S. children was calculated for age groups, sex, and geographic region. Overall, the prescription-opioid overdose ED visits for patients from 0-17 years old in the United States decreased by 22% from 2008 to 2019, then increased by 12% in 2020. Most patients were discharged to home following their ED visit; however, there was a 42% increase in patients admitted from 2019 to 2020. The prescription-opioid overdose rate per 100,000 U.S. children was highest in the 0 to 1 and 12 to 17 age groups, with the 12 to 17 group increasing by 27% in 2020. ED visits in the West and Midwest saw prescription-opioid visits increase by 58% and 20%, respectively, from 2019-2020. Prescription-opioid overdose ED visits among U.S. children and adolescents decreased over the past decade until 2019. However, there was a substantial increase in ED visits from 2019 to 2020, suggesting the potential impact due to the then-emerging COVID-19 pandemic. Findings suggest focusing on young children and adolescents to reduce further prescription-opioid overdoses in the United States.

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.

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. 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. 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. 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.

Affordable housing through the Low-Income Housing Tax Credit program and opioid overdose emergency department visits

IntroductionThe United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk. MethodsWe used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014. ResultsBetween 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00). ConclusionsGiven the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose.

Estimating the uncertain effect of the COVID pandemic on drug overdoses.

U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both. We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends. Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods. The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

County-level social vulnerability and nonfatal drug overdose emergency department visits and hospitalizations, January 2018–December 2020

BackgroundNonfatal drug overdoses (NFODs) are often attributed to individual behaviors and risk factors; however, identifying community-level social determinants of health (SDOH) associated with increased NFOD rates may allow public health and clinical providers to develop more targeted interventions to address substance use and overdose health disparities. CDC’s Social Vulnerability Index (SVI), which aggregates social vulnerability data from the American Community Survey to produce ranked county-level vulnerability scores, can help identify community factors associated with NFOD rates. This study aims to describe associations between county-level social vulnerability, urbanicity, and NFOD rates. MethodsWe analyzed county-level 2018–2020 emergency department (ED) and hospitalization discharge data submitted to CDC’s Drug Overdose Surveillance and Epidemiology system. Counties were ranked in vulnerability quartiles based on SVI data. We used crude and adjusted negative binomial regression models, by drug category, to calculate rate ratios and 95% confidence intervals comparing NFOD rates by vulnerability. ResultsGenerally, as social vulnerability scores increased, ED and hospitalization NFOD rates increased; however, the magnitude of the association varied across drugs, visit type, and urbanicity. SVI-related theme and individual variable analyses highlighted specific community characteristics associated with NFOD rates. ConclusionsThe SVI can help identify associations between social vulnerabilities and NFOD rates. Development of an overdose-specific validated index could improve translation of findings to public health action. The development and implementation of overdose prevention strategies should consider a socioecological perspective and address health inequities and structural barriers associated with increased risk of NFODs at all levels of the social ecology.

An evaluation of the association between specific post-overdose care services in emergency departments and subsequent treatment engagement.

The objective of this study was to estimate the association between receipt of specific post-overdose care services in the emergency department (ED) and subsequent engagement in treatment for opioid use disorder (OUD) after discharge. This was a retrospective cohort study of Rhode Island residents treated at 1 of 4 EDs for opioid overdose who were not engaged in OUD treatment and were discharged home (May 2016-April 2021). Electronic health record data were used to identify ED services received, and state administrative data were used to define subsequent engagement in OUD treatment within 30 days. Multivariable conditional logistic regression was used to estimate the association between ED services received and subsequent treatment engagement. Overall, 1008 people not engaged in OUD treatment were treated at study EDs for opioid overdose and discharged home, of whom 146 (14%) subsequently engaged in OUD treatment within 30 days. Most patients were aged 25 to 44 years (59%) and non-Hispanic White (69%). Receipt of behavioral counseling in the ED (adjusted odds ratio [aOR]=1.79, 95% confidence interval [CI]=1.18-2.71) and initiation of buprenorphine treatment in/from the ED (aOR=5.86, 95% CI=2.70-12.71) were associated with treatment engagement. Receipt of a take-home naloxone kit or naloxone prescription and referral to treatment at discharge were not associated with treatment engagement. Overall, 49% of patients received behavioral counseling in the ED, and 3% initiated buprenorphine in/from the ED. Strategies for increasing provision of behavioral counseling and initiation of buprenorphine in the ED may be useful for improving subsequent engagement in OUD treatment after discharge.

Using synthetic controls to estimate the population-level effects of Ontario's recently implemented overdose prevention sites and consumption and treatment services

Between 2017 and 2020, Ontario implemented overdose prevention sites (OPS) and consumption and treatment services (CTS) in nine of its 34 public health units (PHU). We tested for the effect of booth-hours (spaces within OPS/CTSs for supervised consumption) on opioid-related health service use and mortality rates at the provincial- (aggregate) and PHU-level. We used monthly rates of all opioid-related emergency department (ED) visits, hospitalizations, and deaths between January 2015 and March 2021 as our three outcomes. For each PHU that implemented OPS/CTSs, we created a synthetic control as a weighted combination of unexposed PHUs. Our exposure was the time-varying rate of booth-hours provided. We estimated the population-level effects of the intervention on each outcome per treated/synthetic-control pair using controlled interrupted time series with segmented regression; and tested for the aggregate effect using a multiple baseline approach. We adjusted for time-varying provision of prescription opioids for pain management, opioid agonist treatment (OAT), and naloxone kits; and corrected for seasonality and autocorrelation. All rates were per 100,000 population. For sensitivity analysis, we restricted the post-implementation period to before COVID-19 public health measures were implemented (March 2020). Our aggregate analyses found no effect per booth-hour on ED visits (0.00, 95% CI: -0.01, 0.01; p-value=0.6684), hospitalizations (0.00, 95% CI: 0.00, 0.00; p-value=0.9710) or deaths (0.00, 95% CI: 0.00, 0.00; p-value=0.2466). However, OAT reduced ED visits (-0.20, 95% CI: -0.35, -0.05; p-value=0.0103) and deaths (-0.04, 95% CI: -0.05, -0.03; p-value=<0.0001). Conversely, prescription opioids for pain management modestly increased deaths (0.0008, 95% CI: 0.0002, 0.0015; p-value=0.0157) per 100,000 population, respectively. Except for a few treated PHU/synthetic control pairs, disaggregate results were congruent with overall findings. Booth-hours had no population-level effect on opioid-related overdose ED visit, hospitalization, or death rates.

Risk of peri-intubation adverse events during emergency department intubation of overdose patients: a national emergency airway registry (near) analysis

Background More than 20,000 emergency department (ED) patients undergo intubation for overdose each year. While the characteristics of patients intubated for overdose and poisoning are well described, little is known about the intubation outcomes of overdose patients in the ED. Objectives We quantify the frequency of peri-intubation adverse events for patients intubated in the ED for overdose, and determine whether first attempt success without adverse events differs between patients intubated for overdose and patients intubated for other reasons. Methods We analyzed data from the National Emergency Airway Registry (NEAR), a prospective multicenter registry of ED intubations collected from an international network of 22 academic and community hospitals. We included patients 14 years and older whose first attempt was oral intubation, with data entered into NEAR between 1 January 2016 and 31 December 2018. The primary outcome was successful intubation on the first attempt. We used multivariable logistic regression to determine whether indication was independently associated with successful intubation on the first attempt after adjusting for age, gender, obesity, initial impression of difficult airway, presence of difficult airway characteristics, and use of video laryngoscopy. Secondary outcomes included successful intubation on the first attempt without adverse events, the occurrence of rescue surgical airways, and the occurrence of adverse events. Adverse events included hypoxemia, hypotension, peri-intubation cardiac arrest, bradycardia, mechanical injury to oral or airway structures, vomiting, tachydysrhythmia, esophageal intubation, laryngospasm, and pneumothorax. Results We analyzed 17,984 patients, including 1,983 (11%) intubated for overdose, and 16,001 (89%) intubated for other indications. Patients intubated for overdose were younger (median age 38 vs 55 years), were less frequently obese (26% vs 34%), and fewer had difficult airway characteristics (38% vs 53%). Overdose patients were more likely to have preoxygenation performed (45% vs 35%), more likely to have apenic oxygenation (39% vs 31%), and more likely to have bougie used (33% vs 17%). First attempt success was 90.5% in patients intubated for overdose and 87.5% in patients intubated for other reasons (absolute difference 3.0%; 95% CI: −1.3 to 7.3). First attempt success without adverse events was higher in overdose patients (85.0%) compared to other patients (78.7%) (absolute difference, 6.3%; 95% CI 1.0 to 11.7%). Overdose patients experienced significantly less hypotension (1.5% vs 4.1%), and tended to have fewer adverse events overall. Multivariable model results were consistent with the unadjusted results including no difference in first pass success (adjusted odd ratio 1.02 [95% CI 0.86–1.23]). There was a higher first pass success without complication in patients intubated for overdose (adjusted odds ratio 1.23; 95% CI 1.07 to1.43). Conclusion For patients in whom the primary indication for intubation is overdose there is an increased chance of first attempt success without adverse event.

256 Trends in Opioid Overdoses During the COVID-19 Pandemic

As of April 2022, the United States has reached 100,000 drug related deaths in the year preceding. During the COVID-19 pandemic, the national trend of overall emergency department (ED) visits have decreased, while the number of opioid overdoses have increased. However, it is unclear which patient populations are suffering the most from the compounded effect of the opioid overdose epidemic and the COVID-19 pandemic. The goal of this project was to quantify the number of visits to the Loyola University Medical Center (LUMC) ED for opioid overdose during the COVID-19 pandemic compared to a historical control.

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals.

AimsTo examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre‐pandemic, peak, and re‐opening periods of the first wave of the COVID‐19 pandemic, using corresponding weeks in 2019 as a historical control.DesignPopulation‐based retrospective cohort study conducted between September 30, 2018 and September 26, 2020.SettingOntario, Canada.ParticipantsA total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low‐income housed individuals matched on age, sex, rurality, and comorbidity burden.MeasurementsED visits for drug overdoses of accidental and undetermined intent.FindingsAverage rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7–153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7–24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re‐opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44–1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08–1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02–1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period.ConclusionsRecently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re‐opening period of the COVID‐19 pandemic compared with housed people.

Association between treatment setting and outcomes among oregon medicaid patients with opioid use disorder: a retrospective cohort study

BackgroundResidential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment.MethodsA retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes.ResultsOf 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73–2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80–1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23–0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32–2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56–2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46–1.29; interaction p = 0.001).ConclusionsRelative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

An Examination of Seasonal Trends in Delaware Drug Overdoses, 2016-2020.

ObjectiveTo examine whether overdose deaths and related metrics—overdose calls for service to police and non-fatal overdose emergency department visits—in Delaware follow within-year (i.e., seasonal) patterns during the most recent years of the opioid epidemic (2016-2020).MethodsWe begin by providing descriptive statistics on yearly trends in overdose metrics, followed by Analysis of Variance (ANOVA) to analyze whether seasonal variations have a significant impact on the patterns of Delaware’s overdose metrics while controlling for annual variations.ResultsWe find yearly variations across the three overdose-related metrics, with overdose deaths reporting the only consistent increases per year. Within-year, or seasonal, variations show the spring months have the most consistent increases in overdose deaths and overdose calls for service across years we studied. Finally, we report significant differences for all overdose metrics across years and seasons.ConclusionsAs in prior studies, we find significant variation in overdose-related metrics by season in Delaware.Policy ImplicationsThese findings lend support to existing interventions in slowing yearly growth in overdose deaths. However, allocation of resources and interventions to specific times of the year—when overdoses are highest—may further reduce risks and harms.

Tele-buprenorphine for emergency department overdose visit follow up and treatment initiation.

An ED visit for opioid overdose may be a person's only contact with the medical and behavioral health care systems and is an important opportunity to reduce risk of subsequent overdose and death. While ED initiatives to engage people with opioid use disorder (OUD) are being increasingly implemented, there are significant gaps in the receipt of services at the time of the ED encounter. This is a retrospective cohort study of an outreach pilot project providing real-time telehealth delivered buprenorphine initiation and referral to community harm reduction and addiction treatment services via a follow up telephone call to patients after an ED visit for an opioid overdose. From January 2020 to April 2021 there were 606 patients with an ED visit for an opioid overdose eligible for a callback. Of the 606 eligible patients, 254/645 (42%) patients could be contacted and accepted service and/or treatment referrals. Fifteen patients were connected same-day to a buprenorphine prescriber for a telehealth encounter and, of connected patients, nine received a buprenorphine prescription. A post-ED follow up telephone call protocol is an opportunity to improve treatment engagement and access to buprenorphine for patients at high risk for opioid overdose and death.

Early buprenorphine-naloxone initiation for opioid use disorder reduces opioid overdose, emergency room visits and healthcare cost compare to late initiation

ABSTRACT Background Although the effectiveness of buprenorphine-naloxone (BUP-NX) has been established, real-world evidence on the benefits of early treatment initiation is limited. Objective To evaluate the association between early BUP-NX initiation and health-related outcomes among insured adults with opioid use disorder (OUD). Methods We conducted a cross-sectional analysis using the Optum’s de-identified Clinformatics® Data Mart Database from 2010 to 2018. Patients who initiated BUP-NX within 30 days of OUD diagnosis were classified as early initiators. Patients who initiated BUP-NX later, but within the one-year follow-up, were defined as late initiators. Outcomes included opioid overdose, opioid overdose-related emergency department (ED) visits, and all-cause healthcare cost during the year after OUD diagnosis. We employed generalized linear models to compare outcomes between early and late initiators, adjusting for baseline covariates and accounting for missing information for covariates using multiple imputation. Results A total of 8,388 patients with OUD were identified; mean age was 39.9 years; 36% were female; and 67.6% were early initiators. Early initiators had an estimated 42% lower rate of opioid overdose (adjusted rate ratio (aRR) = 0.58; 95% confidence interval (CI): 0.52, 0.64); 51% lower rate of opioid overdose-related ED visits (aRR = 0.49; 95% CI: 0.44, 0.55); and 31% lower total healthcare cost (adjusted cost ratio = 0.69; 95% CI: 0.66, 0.72), compared to late initiators. Conclusion Compared to late BUP-NX initiation, early initiation was associated with a lower risk of opioid overdose and opioid overdose-related ED visits, and reduced total healthcare cost among insured adult patients with OUD.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

ABSTRACT Background Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. Objective To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. Methods A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. Results Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. Conclusions Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

The impact of the national stay-at-home order on emergency department visits for suspected opioid overdose during the first wave of the COVID-19 pandemic

BackgroundAlthough national syndromic surveillance data reported declines in emergency department (ED) visits after the declaration of the national stay-at-home order for COVID-19, little is known whether these declines were observed for suspected opioid overdose. MethodsThis interrupted time series study used syndromic surveillance data from four states participating in the HEALing Communities Study: Kentucky, Massachusetts, New York, and Ohio. All ED encounters for suspected opioid overdose (n = 48,301) occurring during the first 31 weeks of 2020 were included. We examined the impact of the national public health emergency for COVID-19 (declared on March 14, 2020) on trends in ED encounters for suspected opioid overdose. ResultsThree of four states (Massachusetts, New York and Ohio) experienced a statistically significant immediate decline in the rate of ED encounters for suspected opioid overdose (per 100,000) after the nationwide public health emergency declaration (MA: -0.99; 95 % CI: -1.75, -0.24; NY: -0.10; 95 % CI, -0.20, 0.0; OH: -0.33, 95 % CI: -0.58, -0.07). After this date, Ohio and Kentucky experienced a sustained rate of increase for a 13-week period. New York experienced a decrease in the rate of ED encounters for a 10-week period, after which the rate began to increase. In Massachusetts after a significant immediate decline in the rate of ED encounters, there was no significant difference in the rate of change for a 6-week period, followed by an immediate increase in the ED rate to higher than pre-COVID levels. ConclusionsThe heterogeneity in the trends in ED encounters between the four sites show that the national stay-at-home order had a differential impact on opioid overdose ED presentation in each state.

The impact of codeine upscheduling on overdoses, Emergency Department presentations and mortality in Victoria, Australia

Background and aimsPrior to February 2018, codeine was available over-the-counter (OTC) in Australia as a pharmacist-only medicine (Schedule 3) in low-strength formulations when in combination with simple analgesics. In February 2018, The Advisory Committee on Medicines Scheduling (ACMS) upscheduled codeine-containing medicines (CCM) to Schedule 4 (prescription-only medicine). This study aimed to determine the impact of upscheduling on prescriptions, overdoses and deaths. MethodsThis study used interrupted time series analysis, a quasi-experimental design, to retrospectively evaluate the impact of upscheduling on overdose poisoning calls to the Victorian Poisons Information Centre (VPIC), Emergency Department (ED) presentations to Austin Health, and deaths reported to the Victorian Coroner from 1 January 2013–31 December 2019. ResultsThere was a significant reduction in the trend of high-strength codeine poisoning calls by 0.36 (P = 0.03, 95 % CI = [−0.69, −0.04]). Low-strength codeine poisoning calls to the VPIC reduced by 13.31 (P <0.001, 95 % CI = [−16.80, 9.82]]) calls in February 2018, followed by continued reduction of 0.12 calls per month. High-strength codeine overdose ED presentations reduced in the first quarter of 2018 by 3.72 presentations (P = 0.004, 95 % CI = [−6.13, −1.31]). Low-strength codeine overdose ED presentations after the first quarter of 2018 by 0.33 (P = 0.03, 95 % CI = [−0.63, −0.03]) presentations per month. Codeine-related deaths reduced by 7.19 (P < 0.001, 95 % CI = [−9.44, −4.94]) deaths in February 2018. ConclusionsCodeine upscheduling to prescription-only medicine has reduced codeine-related poisoning calls, overdoses and unnatural death in Victoria.

Brief Report: The Impact of COVID-19 on Emergency Department Overdose Diagnoses and County Overdose Deaths.

Background and ObjectivesWe sought to understand the impact of COVID‐19 on emergency department (ED) overdoses and county coroner verified overdose deaths.MethodsElectronic medical health record and county coroner data were gathered and comparisons were made between three 16‐week time periods. In the three time periods, 873 individuals had an overdose diagnosis in the ED and 440 individuals in the county died of drug overdose.ResultsWhile total ED patient volume decreased substantially, the number of ED overdose patients increased between March 6 and June 25, 2020. Furthermore, during this same period, coroner data revealed an increase in overdose deaths.Conclusion and Scientific SignificanceThis preliminary evidence provides a key insight into the impact of COVID‐19 on both overdose presentations to the ED and county overdose deaths. These results emphasize the critical need for increasing vigilance to prevent overdose by continuously developing and optimizing both accessible and quality treatment as we navigate through this pandemic and its ongoing effects on persons with substance use disorder. (Am J Addict 2021;00:00–00)