Follow-up treatments after opioid overdose rare among insured patients

Black patients were also less likely to receive treatments after ER visit for opioid use

PHILADELPHIA -- The majority of commercially insured patients who visited the emergency department (ED) for an opioid overdose didn't receive the timely follow-up care known to help prevent a future overdose or death, according to a new study from researchers at the Perelman School of Medicine at the University of Pennsylvania. Of nearly 6,500 patients treated in EDs nationwide for an overdose or other opioid-related medical complications, only 16 percent accessed opioid use disorder (OUD) medications or another form of treatment within three months of the ED visit. The study was published today in JAMA Network Open.

The lack of care was most pronounced among black patients, who were half as likely to receive post-overdose treatment as whites, even after adjusting for type of overdose (prescription or heroin), and other clinical characteristics. Timely follow-up treatments are known to significantly reduce the risk of death among patients suffering from opioid use disorders who are admitted to the ED.

"The ED encounter has been seen as a critical opportunity to engage a patient and connect them to the right care that gives them the best chance for recovery," said the study's first author Austin Kilaru, MD, an emergency department physician and a fellow in the National Clinician Scholars Program at Penn. "However, even with commercially insured patients, who likely have superior ability to access care, we see these low treatment rates, particularly for minorities. There's more work to be done, and these findings give us a comprehensive picture of the gaps and disparities that could help inform those efforts moving forward."

The team analyzed administrative insurance claims under a large commercial insurer filed between October 2011 and September 2016. Researchers defined follow-up treatments as the prescription of medication for opioid use disorder (MOUD)--buprenorphine and naltrexone--or an outpatient or inpatient opioid treatment encounter, which could include behavioral health services or primary care visits. While the study did include two MOUDs shown to reduce the risk of death and overdoses, it did not capture the use of methadone, another common MOUD, because the insurer did not cover it at the time.

Of the 6,451 adult patients treated in EDs nationwide, 4,555 overdosed from prescription opioids and 1,896 overdosed from heroin. Nearly 75 percent of the patients identified as non-Hispanic white and about 10 percent identified as black. Within that group, only 1,069 received follow-up care after being discharged from the ED. Most notably, black patients were half as likely to obtain treatment following overdose compared with white patients (6.1 percent versus 12.1 percent). Hispanic and female patients were also less likely to receive treatments.

Researchers found that patients who had received treatment prior to being admitted to ED were more likely to receive follow-up care. In fact, more than 62 percent of patients who had received prior treatment for an overdose received the follow-up care. Among patients who did not receive treatment 90 days prior to the ED visit (5,769), only about 10 percent--or 643--received follow-up care.

The findings demonstrate that there are barriers to follow-up care beyond being underinsured or uninsured and other factors limiting access that warrant further attention.

Increased adoption of pathways to initiate buprenorphine in the ED, more coordinated communication between EDs and outpatient clinics, and direct conversations between physicians and patients around treatments may help improve that access. These interventions, the authors said, must seek to reduce racial, ethnic, and gender disparities to ensure expanded and equitable access to treatment following overdose.

Since the study time period ended, some hospitals across the country have implemented changes to help address this issue. For example, Penn established its Center for Opioid Recovery and Engagement (CORE), which has helped improve the pathway to recovery for many patients, regardless of insurance status, by implementing such efforts and more.

"The period after an overdose is so high risk that we need to be able to use that key window of opportunity," Kilaru said. "Payers and policymakers should push for strategies that encourage, help, and incentivize health systems to deliver the timely follow-up care we know can save more lives."

Additional Penn authors on the study include Aria Xiong, MS, Margaret Lowenstein, MD, Zachary F. Meisel, MD, Jeanmarie Perrone, MD, Utsha Khatri, MD, Nandita Mitra, PhD, and M. Kit Delgado, MD.

The work was supported by a pilot grant from the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

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The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $425 million awarded in the 2018 fiscal year.

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