Study: Medicaid Patients With ED Visits For Overdose: Disparities In Initiation Of Medications For Opioid Use Disorder (DOI 10.1377/hlthaff.2024.00984)
Medications proven to effectively treat opioid addiction are rarely given after emergency department visits for overdose, and who gets them varies, sometimes greatly, depending on race, ethnicity or geography, University of Michigan researchers say.
In their study analyzing 100% of Medicaid claims from all 50 states and Washington, D.C., between 2016-2020, the researchers found that a mere 6% of patients being treated for overdoses, or about 1 in 16, started treatment with any of the three medications for opioid use disorder, or MOUD, within 30 days of leaving the hospital.
"The emergency department offers a critical window of time to initiate MOUD. It's critical because we know that patients who are discharged from the ED after a nonfatal opioid overdose are at increased risk of experiencing a fatal overdose within the next twelve months," said Thuy Nguyen, assistant professor of health management and policy at the U-M School of Public Health and founder and director of the Michigan-Substance Use Policy and Economic Research Network.
According to the study published in Health Affairs, the most stark difference in treatment was seen in race with 7.3% of white patients receiving medication to begin treatment for opioid use disorder compared to 4.3% of Black patients, 5.2% of Asian patients, 5.4% of American Indian and Alaska Native patients and 4.9% of Hispanic patients. The study was based on a sample of 249,735 emergency department visits involving 214,101 patients ages 15-64 years old.
The study also broke down differences in which specific drugs were prescribed, buprenorphine, methadone or extended-release naltrexone, within 30 days of discharge from emergency department visits for overdose and also sorted patient demographics by geography and race/ethnicity.
Among the 249,735 visits used in the study, 69% were for white patients, 17.7% were for Black patients, 10% were for Hispanic patients, 2.1% were for American Indian and Alaska Native patients, 0.6% were for Asian patients and 0.5% were for patients of another race. Of the visits, 4.7% were associated with claims for buprenorphine, 1% with methadone claims and 0.8% of claims for extended-release naltrexone.
"The gap between Black and white patients got even wider during the study period," Nguyen said. "This is especially worrying because overdose deaths and emergency visits involving opioids have been rising faster among Black patients."
Opioid overdoses, including synthetic opioids such as fentanyl, took approximately 81,000 lives in the U.S. in 2023, a decrease of about 2,000 deaths from the prior year and the first downturn in all drug overdoses since 2018, according to provisional data from the U.S. Centers for Disease Control Prevention.
Still, overdose deaths and opioid addiction remain a major public health concern that harms families and friends and also negatively impacts communities and economies by taxing social services, law enforcement agencies and health care systems. Medicaid is the largest payer of substance use disorder treatment in the U.S., covering about 38% of nonelderly adults with opioid use disorder as of 2019.
"There are many reasons for the low rate of initiating MOUD in the ED, including stigma toward opioid addiction, lack of clinician education on the management of this condition, and lack of time," Nguyen said. "It is possible that race and ethnicity are proxies for some of these factors, leading to the differences in MOUD initiation rates that we report in this study."
Geographically, the U.S. Northeast had the most patients who had been treated for overdose at 8.6%. In the Midwest, the rate was 6.5% compared to 5.5% in the South and 5% in the West, where the disparity in treatment between Black and white patients was lowest.
When looking at rural vs. urban patients, the differences were not substantial.
Nguyen and colleagues urge health care providers to use the study to tailor care around the needs and disparities that affect different patients.
Increasing the initiation of opioid addiction medications in the emergency department could also benefit hospitals by preventing patients, many of whom have no primary care doctor, from returning to the ED for another overdose, thus reducing the strain on an already overwhelmed system.
"Intervening at the time of the overdose emergency is beneficial for everyone, in many ways," Nguyen said. "It's also important to note the patient role, adherence, and other barriers to MOUD access after discharge."
Study co-authors, all from U-M, include: Yang (Amy) Jiao, Stephanie Lee, Pooja Lagisetty, Amy Bohnert, Keith Kocher, Kao-Ping Chua.
