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Disparities in Follow-up Care After Nonfatal Opioid Overdoses

October 1, 2020
A 2011-2019 review of emergency department discharges shows a low and varied range of opioid overdose follow-up treatment, whether the opioid was prescribed or illicit.

A PPM Brief with Austin Kilaru, MD, an emergency physician at Perelman School of Medicine

After seeing a continued increase in emergency room visits for complications of opioid use –both overdoses and other complications – ER physicians at the Perelman School of Medicine at the University of Pennsylvania began to wonder if emergency departments were doing enough for patients.

“We realized that it is no longer enough to just stabilize these patients and send them home,” said Austin Kilaru, MD, an emergency physician at Perelman. “We wanted to get a baseline for how often,  when patients leave the ER, they actually make it to a follow-up appointment, get to a clinic for follow-up treatments, or fill that prescription for buprenorphine – and we wanted to look at that on a national level.” Dr. Kilaru and his team designed a study to do just that.

“We realized that it is no longer enough to just stabilize [opioid overdose] patients and send them home,” said Austin Kilaru, MD. (Image: iStock)

 

Methods

Their findings, published this past May 2020 in JAMA Network Open, were based on a retrospective cohort study looking at data from the administrative claims database of a large US commercial insurer during the period from October 1, 2011 to September 30, 2019. De-identified records of adult patients who had been discharged from the ED after an opioid overdose were considered for analysis. Encounters of patients who did not have continuous insurance coverage for 90 days before, and 90 days after, the overdose were excluded, as were those of patients with pain related to an active cancer diagnosis. Also excluded were encounters of patients who had had an overdose in the previous 90 days and those who were admitted to the hospital. In the end, 6,451 patient-encounters were selected for inclusion in the review.

Dr. Austin and team defined “follow-up” treatment as medication (prescription given, filled) for opioid use disorder (OUD) or follow-up inpatient or outpatient care, which included psychiatric services, behavioral health services, and case management.To determine whether patients had received these follow-up treatments, they checked the insurer’s records of pharmacy claims for national drug codes for all formulations of buprenorphine, buprenorphine with naloxone, or naltrexone. Medical claims for ICD-9-CM or ICD-10-CM diagnosis codes for OUD were used to identify the referrals to clinics.

 

Findings

Of the 6,451 patients reviewed, only 16.6% received follow-up treatment in the 90 days following an overdose. Of patients who were not receiving active addiction treatment at the time of overdose, only 11.1 % received follow-up treatment after an overdose. Interestingly, patients who had overdosed on prescription opioids were less likely than those who had overdosed on heroin to get follow-up treatment. Black and Hispanic patients were less likely to get follow-up treatment than non-Hispanic Whites. Women were less likely than men to receive follow-up treatment as well.

“We expected the rate of follow-up to be low,” Dr. Kilaru, lead investigator on the study, told PPM, pointing out that not everyone who is seen for an overdose in the ED needs this kind of follow-up. “Sometimes the overdose can be accidental. For example, someone is older and takes too many medications. That patient still needs follow-up care to see why they overdosed, but they don’t necessarily have opioid use disorder.” Still, the results were surprising. “We weren’t expecting it to be this low (ie, 16.6%), particularly because the patients in the study had commercial insurance, so presumably had access to a primary care physician and specialist physicians.”

But the biggest surprise was the racial disparity, Dr. Kilaru said. “Even when you adjust for multiple factors, the follow-up rate for Black patients was half that for White patients.”

 

What’s the Solution for a Lack of Overdose Follow-up?

The Perelman review did not look at reasons behind these disparities as teasing out the many inter-related factors can be difficult. Nonetheless, Dr. Kilaru says that systemic barriers may be the root of the problem. “It is really mind-bogglingly hard to navigate the healthcare system. Once you walk out of the hospital with a piece of paper, how do you make that appointment? How do you get to the appointment? By the time you get to the appointment, are you still motivated to get treatment? There is a cascade of barriers that prevents people from making it to that crucial next step.”

The solution, according to Dr. Kilaru does not rest entirely with clinicians; it requires a larger, systemic change. “On any given shift, I can work very hard on a particular patient, arrange follow-up, arrange counseling, give them a prescription, but unless there’s a system to take care of them, all the work I’ve put into helping that one patient is going to be forgotten. We need an integrated system that meets patients where they are – whether that’s in the emergency department or the clinic – where we can hand patients off to a dedicated counselor, to somebody who can follow-up with that patient even after the patient has left the hospital.”

As with so many problems in healthcare today, the answers are complex. Studies like this one can ideally help clinicians and policymakers determine where to focus their efforts.

 

See a conversation with Drs. Johnathan Goree and Carmen R. Green on racial disparities across the pain management spectrum in our Fall 2020 Side Chat.

 

Last updated on: October 6, 2020
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Special Report: Race, Pain Management, and the System
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