Assessment of Patient-Reported Naloxone Acquisition and Carrying With an Automated Text Messaging System After Emergency Department Discharge in Philadelphia.

Importance: A central tenet of harm reduction and prevention of opioid overdose deaths is the distribution and use of naloxone. Patient-centered methods that investigate naloxone acquisition and carrying can guide opioid overdose education and naloxone distribution efforts. Objective: To assess patients' self-reported naloxone acquisition and carrying after an emergency department (ED) encounter using automated text messaging. Design, Setting, and Participants: This cohort study investigated self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia, Pennsylvania. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record provided informed consent after ED discharge, and data were collected prospectively using text messaging from October 10, 2020, to March 19, 2021. Patients who did not respond to the survey or who opted out were excluded. Exposure: Automated text message-based survey after ED discharge for patients who were prescribed or dispensed naloxone. Main Outcomes and Measures: The primary outcome was patient-reported naloxone acquisition, carrying, and use. Descriptive statistics were used to summarize patient demographic characteristics. Results: Of 205 eligible patients, 41 (20.0%) completed the survey; of those patients, the mean (SD) age was 39.5 (13.7) years, and 21 (51.2%) were women. Fifteen (36.6%) had a personal history of being given naloxone after an overdose. As indicated by the ED record, 27 participants (65.9%) had naloxone dispensed in the ED, and 36 (87.8%) self-reported acquiring naloxone during or after their ED visit. Twenty-four participants (58.5%) were not carrying naloxone in the week before their ED visit. Twenty participants (48.8%) were carrying naloxone after the ED visit, and 27 (65.9%) reported planning to continue carrying naloxone in the future. Of the 24 individuals (58.5%) not carrying naloxone before their ED encounter, 13 (54.2%) reported planning to continue carrying naloxone in the future. Conclusions and Relevance: In this cohort study of adult patients dispensed or prescribed naloxone from the ED, most reported acquiring naloxone on or after discharge. The ED remains a key point of access to naloxone for individuals at high risk of opioid use and overdose, and text messaging could be a method to engage and motivate patient-reported behaviors in enhancing naloxone acquisition and carrying.

Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal.

OBJECTIVE: To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone. METHODS: This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals. RESULTS: 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016. CONCLUSIONS: Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.

Incidence of Treatment for Opioid Use Disorder Following Nonfatal Overdose in Commercially Insured Patients.

Importance: Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. Objective: To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. Design, Setting, and Participants: A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. Main Outcomes and Measures: The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. Results: A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). Conclusions and Relevance: Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.

Impact of a State Opioid Prescribing Limit and Electronic Medical Record Alert on Opioid Prescriptions: a Difference-in-Differences Analysis.

BACKGROUND: Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact. OBJECTIVE: Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters. DESIGN: Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018). PARTICIPANTS: Adults with new opioid prescriptions in an academic health system with practices in PA and NJ. INTERVENTIONS: State 5-day opioid prescribing limit plus health system and health system EMR alert. MAIN MEASURES: Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics. KEY RESULTS: There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions. CONCLUSIONS: Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.

Facing Financial Hardship: Patients' Views on Clinical Trade-offs in Exchange for Cost Savings.

As more patients enroll in health insurance with high out-of-pocket costs, provider-patient cost discussions are of growing importance. Little is known about how patients want providers to engage in cost conversations. We surveyed 842 chronically ill adults seeking financial help to examine preferences around treatment trade-offs in 3 areas-convenience, side effects, and efficacy and whether preferences changed with different savings. To save money, half of patients were willing to endure inconvenience (increased dosing), with no difference by magnitude of savings ($50 vs $150 per month). Few participants were willing to tolerate side effects or reduced efficacy.

Addressing cost barriers to medications: a survey of patients requesting financial assistance.

OBJECTIVES: Given that many patients with chronic diseases face cost-related barriers to care, we evaluated patients' views on which providers (both physicians and nonphysicians) to involve and which methods to use to screen for those barriers. We also examined patients' preferences for how physicians consider cost-efficacy trade-offs in decisions. STUDY DESIGN: A national survey of 1400 randomly sampled adults with a chronic disease seeking financial assistance (842 respondents). METHODS: Participants rated their comfort with various providers and tools for identifying cost barriers. Then they rated a randomly assigned clinical vignette that described how a clinical decision was made in the context of a cost-efficacy tradeoff. Vignettes depicted 3 decision types: cost-conscious physician, cost-indifferent physician, or patient-directed. Comfort was rated from 1 to 10-ratings above 7 indicated high comfort. RESULTS: More respondents reported high comfort with physicians screening for cost barriers (81.1%) than with pharmacists (74.8%; P=.002), nurses (69.4%; P<.001), professional counselors (68.3%; P<.001), and trained volunteers (50.5%; P<.001). Regarding screening for cost barriers using administrative records, more respondents reported higher comfort with doctors' offices (58.8%) than with insurance companies (53.3%; P=.03), but similar levels of comfort compared to pharmacies (62.1%; P=.17). Participants favored "patient-directed" decisions with physician input (odds ratio, 4.64; 95% CI, 3.14-6.84; P<.001) compared with "cost-conscious" decisions in which physicians unilaterally decided how to manage cost-efficacy tradeoffs. CONCLUSIONS: Patients were open to a range of cost-barrier screening approaches, but most favor direct conversations with their doctor and shared decision making in decisions involving cost-efficacy trade-offs.