Unexpected Gaps in Opioid Overdose Treatments
Opioid overdoses and related mortality remain a serious problem, which means “it’s important for clinicians to take advantage of every opportunity to prescribe lifesaving medications like naloxone and buprenorphine,” says Kao-Ping Chua, MD, PhD, an assistant professor of pediatrics and health services researcher with the Susan B. Meister Child Health Evaluation and Research Center at the University of Michigan.
Naloxone and buprenorphine can avert disasters, but “most EDs are not prescribing these medications to patients presenting with opioid overdose, potentially owing to factors such as stigma, lack of time, [and] lack of awareness of the importance of these medications,” Chua notes.
Chua and colleagues analyzed 148,966 ED visits for opioid overdose that occurred between 2019 and 2021.1 Only one in 13 patients received a naloxone prescription within 30 days of the ED visit for opioid overdose. “In contrast, almost half of patients with an ED visit for anaphylaxis received a prescription for epinephrine, another lifesaving rescue medication,” Chua notes.
Additionally, only one in 12 patients received a buprenorphine prescription within 30 days. “These low rates of prescribing occurred against a backdrop of rapidly escalating numbers of opioid overdose deaths,” Chua laments.
Patients presenting to EDs for opioid overdose should go home with a naloxone prescription or a naloxone take-home kit. Alternatively, these patients could start buprenorphine when it is clinically feasible, or they could be connected directly to outpatient treatment for opioid use disorder.
These findings are consistent with the work of previous researchers who found low rates of naloxone and buprenorphine dispensing after ED visits for opioid overdose among privately insured patients.2,3 “In that sense, the findings are not particularly surprising, but they are still sobering,” Chua adds.
Elsewhere, a group of investigators analyzed 15 randomized, controlled trials that included 3,852 participants and 36 observational cohort studies that included 749,634 patients. They noted generally lower rates of all-cause mortality, drug-related deaths, and suicide among patients who were on opioid agonist treatment.4
In a New Jersey-centric investigation of opioid overdoses that occurred between 2014 and 2019, lead author Stephen Crystal, MA, PhD, was alarmed by the shift from overdoses of prescription opioid analgesics to overdoses involving fentanyl-adulterated street drugs. Further, he was struck by the complex patterns of mental health and non-opioid substance use disorder, which are increasingly typical of patients who present with opioid overdose.5
“This highlights the urgent need for ED to develop strategies for managing and referring patients who present with opioid overdose that immediately engage them in treatment,” says Crystal, director of the Rutgers University Center for Health Services Research.
Crystal suggests providers initiate buprenorphine during the ED visit, with patients leaving the department with a prescription to bridge them to a follow-up outpatient visit. Arrange consultations with addiction psychiatry specialists during the visit. Importantly, give patients a “warm handoff” for follow-up care — ideally, with an appointment for a provider he or she already “met” via phone or video call while in the facility.
“Given the rapid spread of fentanyl in street drugs, the ED needs to connect with partner organizations to expand its public health role, from simply providing acute treatment to becoming a bridge for recovery,” Crystal says.
REFERENCES
- Chua KP, Dahlem CHY, Nguyen TD, et al. Naloxone and buprenorphine prescribing following US emergency department visits for suspected opioid overdose: August 2019 to April 2021. Ann Emerg Med 2021 Nov 18;S0196-0644(21)01349-4. doi: 10.1016/j.annemergmed.2021.10.005. [Online ahead of print].
- Kilaru AS, Liu M, Gupta R, et al. Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal. Am J Emerg Med 2021;47:154-157.
- Kilaru AS, Xiong A, Lowenstein M, et al. Incidence of treatment for opioid use disorder following nonfatal overdose in commercially insured patients. JAMA Netw Open 2020;3:e205852.
- Santo T Jr, Clark B, Hickman M, et al. Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: A systematic review and meta-analysis. JAMA Psychiatry 2021;78:979-993.
- Crystal S, Nowels M, Olfson M, et al. Medically treated opioid overdoses among New Jersey Medicaid beneficiaries: Rapid growth and complex comorbidity amid growing fentanyl penetration. J Subst Abuse Treat 2021;131:108546.
Patients presenting to EDs for opioid overdose should go home with a naloxone prescription or a naloxone take-home kit. Alternatively, these patients could start buprenorphine when it is clinically feasible, or they could be connected directly to outpatient treatment for opioid use disorder.
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