Abstract
In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. (Am J Public Health. 2023;113(4):372–377. https://doi.org/10.2105/AJPH.2022.307213)
In 2021, more than 107 000 people died of an overdose in the United States, a 15% increase from 2020.1 With rising overdose deaths, hospitals and emergency departments (EDs) have expanded treatment and harm-reduction services for patients with opioid use disorder (OUD), including distribution of the opioid antagonist naloxone. As a primary treatment site for opioid overdose and OUD, EDs are optimal settings for naloxone distribution and other harm-reduction services.2
INTERVENTION AND IMPLEMENTATION
To help standardize and improve ED postoverdose and OUD care, in 2017, the Rhode Island Department of Health (RIDOH) and the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals established statewide treatment standards for opioid overdose and OUD in EDs and hospitals (known as the “Levels of Care” policy).3 The policy outlines three levels of certification based on facilities’ opioid-related care, with level 1 designating provision of the most comprehensive care and level 3 the minimum treatment standard, and requires all EDs to offer a take-home naloxone kit or naloxone prescription to patients with suspected opioid overdose.3,4 Previously, ED provision of take-home naloxone was at the discretion of the provider.
RIDOH provided technical assistance to all EDs in Rhode Island to develop and implement protocols in alignment with state policy. This included site visits, review of existing protocols, training of staff, development of patient education materials, and additional implementation support as needed.5 In the 21 months following policy implementation, 82% of ED patients treated for an opioid overdose were offered take-home naloxone, but less than half received it.6 While barriers and facilitators to overall policy implementation have been described previously,5 patient- and facility-level factors influencing provision of take-home naloxone are unknown.
PLACE, TIME, AND PERSONS
Rhode Island has one of the highest rates of overdose death in the United States, ranking 13th in 2020.7 In 2020, the age-adjusted rate of overdose death was 38.2 deaths per 100 000 residents in Rhode Island (vs 28.3 deaths per 100 000 residents nationally).7,8
The ED treatment standards policy was released in March 2017, and ED naloxone distribution protocols were implemented from March 2017 to June 2018 across all Rhode Island EDs. We evaluated ED distribution of take-home naloxone from nine Rhode Island acute care hospital EDs from January 1, 2018, to December 31, 2019, following policy implementation. Opioid overdose visits to psychiatric and obstetric/gynecologic specialty hospitals were rare and excluded from this analysis.
Our study included all adult patients treated and discharged from a Rhode Island ED after a suspected opioid overdose. Data were obtained from a RIDOH overdose surveillance system to which all Rhode Island EDs are mandated to report suspected opioid overdoses.9 We excluded patients who were minors, who were incarcerated, who died, who were admitted to the hospital, who left the ED against medical advice, who left without being seen, or who were transferred to another facility.
PURPOSE
The statewide treatment standards aim to improve postoverdose ED care to reduce overdose deaths. Providing take-home naloxone is one component of this strategy. Identifying factors associated with provision of take-home naloxone to ED patients treated for a suspected opioid overdose is essential for improving postoverdose naloxone access.3
EVALUATION AND ADVERSE EFFECTS
We aimed to identify patient- and facility-level factors associated with provision of take-home naloxone for ED patients treated after an opioid overdose. From January 1, 2018, to December 31, 2019, 1900 people presented to EDs in Rhode Island for opioid overdose at 2009 unique visits that met inclusion criteria. At more than half of these visits (58.2%; n = 1170) take-home naloxone was provided at discharge, either directly (1110 kits distributed from the ED) or via prescription (60 naloxone prescriptions sent to a pharmacy; Table 1). The primary formulation distributed by hospitals was intranasal.
TABLE 1—
Patient Characteristics and Emergency Department Services and Characteristics Among Emergency Department Visits for Opioid Overdose: Rhode Island, 2018‒2019
| All Visits (n = 2009), No. (%) | Received Take-Home Naloxone Kit or Naloxone Prescription at Discharge (n = 1170), No. (%) | Did Not Receive Take-Home Naloxone Kit or Naloxone Prescription at Discharge | |||
| Already Had Naloxone (n = 58), No. (%) | Declined Naloxone (n = 453), No. (%) | Not Offered Naloxone (n = 328), No. (%) | |||
| Patient characteristics | |||||
| Sex | |||||
| Male | 1357 (67.5) | 805 (68.8) | 45 (77.6) | 301 (66.4) | 206 (62.8) |
| Female | 652 (32.5) | 365 (31.2) | 13 (22.4) | 152 (33.6) | 122 (37.2) |
| Age, y | |||||
| 18–24 | 313 (15.6) | 180 (15.4) | 5 (8.6) | 75 (16.6) | 53 (16.2) |
| 25–34 | 811 (40.4) | 458 (39.1) | 31 (53.4) | 193 (42.6) | 129 (39.3) |
| 35–44 | 494 (24.6) | 293 (25.0) | 15 (25.9) | 104 (23.0) | 82 (25.0) |
| 45–54 | 235 (11.7) | 145 (12.4) | a | 45 (9.9) | 42 (12.8) |
| ≥ 55 | 156 (7.8) | 94 (8.0) | a | 36 (7.9) | 22 (6.7) |
| Race | |||||
| Black or African American | 124 (6.2) | 82 (7.0) | a | 20 (4.4) | 21 (6.4) |
| White | 1400 (69.7) | 782 (66.8) | 51 (87.9) | 342 (75.5) | 255 (68.6) |
| Other | 69 (3.4) | 44 (3.8) | a | 12 (2.6) | 12 (3.7) |
| Unknown | 416 (20.7) | 262 (22.4) | 5 (8.6) | 79 (17.4) | 70 (21.3) |
| Ethnicity | |||||
| Hispanic | 106 (5.3) | 77 (6.6) | a | 11 (2.4) | 15 (4.6) |
| Non-Hispanic | 1122 (55.8) | 605 (51.7) | 45 (77.6) | 285 (62.9) | 187 (57.0) |
| Unknown | 781 (38.9) | 488 (41.7) | 10 (17.2) | 157 (34.7) | 126 (38.4) |
| Previous ED visit for opioid overdose in past 12 mo | |||||
| Yes | 297 (14.8) | 167 (14.3) | 13 (22.4) | 80 (17.7) | 37 (11.3) |
| No | 1712 (85.2) | 1003 (85.7) | 45 (77.6) | 373 (82.3) | 291 (88.7) |
| Naloxone administered before ED presentation | |||||
| Yes | 1671 (83.2) | 1005 (85.9) | 49 (84.5) | 378 (83.4) | 239 (72.9) |
| No | 294 (14.6) | 141 (12.1) | 9 (15.5) | 63 (13.9) | 81 (24.7) |
| Unknown | 44 (2.2) | 24 (2.1) | 0 (0.0) | 12 (2.6) | 8 (2.4) |
| ED services offered or received | |||||
| Offered behavioral counseling | |||||
| Yes | 1711 (85.2) | 1057 (90.3) | 52 (89.7) | 439 (96.9) | 163 (49.7) |
| No | 82 (4.1) | 29 (2.5) | a | a | 50 (15.2) |
| Unknown | 216 (10.8) | 84 (7.2) | 5 (8.6) | 12 (2.6) | 115 (35.1) |
| Received behavioral counseling | |||||
| Yes | 661 (32.9) | 542 (46.5) | 8 (13.8) | 45 (9.9) | 66 (20.1) |
| No | 1132 (56.3) | 544 (46.5) | 45 (77.6) | 396 (87.4) | 147 (44.8) |
| Unknown | 216 (10.8) | 84 (7.2) | 5 (8.6) | 12 (2.6) | 115 (35.1) |
| Received referral at dischargeb | |||||
| Yes | 382 (19.0) | 271 (23.2) | 9 (15.5) | 37 (8.2) | 65 (19.8) |
| No | 1627 (81.0) | 899 (76.8) | 49 (84.5) | 416 (91.8) | 263 (80.2) |
| ED by certification level | |||||
| Level 1 (comprehensive care) | |||||
| Hospital A | 635 (31.6) | 428 (36.6) | a | 111 (24.5) | 94 (28.7) |
| Hospital B | 404 (20.1) | 143 (12.2) | 32 (55.2) | 185 (40.8) | 44 (13.4) |
| Hospital C | 303 (15.1) | 199 (17.0) | 5 (8.6) | 37 (8.2) | 62 (18.9) |
| Hospital D | 176 (8.8) | 146 (12.5) | a | 17 (3.8) | 9 (2.7) |
| Hospital E | 55 (2.7) | 39 (3.3) | a | 10 (2.2) | 5 (1.5) |
| Hospital F | 39 (1.9) | 28 (2.4) | a | 7 (1.5) | a |
| Level 3 (minimum standard of care) | |||||
| Hospital G | 266 (13.2) | 112 (9.6) | 7 (12.1) | 64 (14.1) | 83 (25.3) |
| Hospital H | 82 (4.1) | 46 (3.9) | a | 8 (1.8) | 25 (7.6) |
| Hospital I | 49 (2.4) | 29 (2.5) | a | 14 (3.1) | a |
Note. ED = emergency department.
Counts of 1–4 are suppressed to prevent potential identification of patients and protect their confidentiality, in accordance with the Rhode Island Department of Health Small Numbers Policy.
Includes referrals to substance use treatment, opioid treatment programs, recovery services, and inpatient detoxification programs.
Among the 1170 visits where naloxone was distributed from the ED, most patients were White (66.8%; n = 782), male (68.8%; n = 805), and aged 25 to 34 years (39.1%; n = 458), as originally recorded in the patient’s electronic health record. Among visits where naloxone was not provided (839 visits), more than half declined (54.0%; n = 453), more than a quarter were not offered take-home naloxone (39.1%; n = 328), and a minority reported already having naloxone (6.9%; n = 58).
There were no meaningful differences in patient demographics between different categories of naloxone receipt, and most of our analytic sample was White, male, and young. These demographics reflect the overall composition of people treated in the ED for an opioid overdose.10 Individuals who died from an opioid overdose had similar race and sex demographic composition but were slightly older compared with the study population (20%–23% of opioid overdose deaths in 2018 and 2019 were among people aged 25 to 34 years).11,12 Potential explanations for the relatively little diversity found in our analytic sample include limitations of race data recorded in electronic health records, that Rhode Island is a predominantly White state, and potential selection bias in our study because we only included people who were treated in an ED following their opioid overdose.
We fit a multivariable log-binomial regression model specified a priori to estimate the association between patient- and facility-level characteristics and provision of take-home naloxone. Regional frequency of opioid overdose, ED certification level, and administration of naloxone before ED presentation were associated with receipt of take-home naloxone in the ED; these associations were conditional on patient sex, age, race, and whether the patient had a previous ED visit for opioid overdose within the past 12 months (Table 2).
TABLE 2—
Characteristics Associated With Receipt of Take-Home Naloxone at Emergency Department Visits for Opioid Overdose: Rhode Island, 2018‒2019
| ED Naloxone Distribution, Adjusted Prevalence Ratio (95% CI)a | |
| Sex | |
| Male | 1 (Ref) |
| Female | 0.94 (0.87, 1.02) |
| Age, y | |
| 18–24 | 1 (Ref) |
| 25–34 | 0.93 (0.84, 1.04) |
| 35–44 | 0.95 (0.85, 1.06) |
| 45–54 | 1.04 (0.91, 1.19) |
| ≥ 55 | 0.99 (0.85, 1.15) |
| Race | |
| Black or African American | 1.04 (0.91, 1.19) |
| White | 1 (Ref) |
| Other | 1.08 (0.91, 1.28) |
| Unknown | 1.00 (0.92, 1.10) |
| Previous ED visit for opioid overdose in past 12 mo | |
| Yes | 0.94 (0.84, 1.04) |
| No | 1 (Ref) |
| Naloxone administered before ED presentation | |
| Yes | 1.29 (1.14, 1.46) |
| No | 1 (Ref) |
| ED certification level | |
| Level 1 (comprehensive care) | 1.18 (1.05, 1.33) |
| Level 3 (minimum standard of care) | 1 (Ref) |
| Regional frequency of EMS calls for opioid overdose annually | |
| < 100b | 1 (Ref) |
| 100–200c | 0.90 (0.82, 0.99) |
| > 200d | 1.21 (1.10, 1.33) |
Note. CI = confidence interval; ED = emergency department; EMS = emergency medical services. Multivariable log-binomial regression model fit to n = 1965 ED visits with complete information (97.8% of total study population from Table 1).
Prevalence ratio for ED naloxone distribution. Outcome of ED naloxone distribution collapsed into binary yes/no variable. Model variables included patient characteristics (sex, age, race, ethnicity, ED visit for opioid overdose in past 12 mo, naloxone given before ED arrival), ED certification level (level 1 vs level 3), and annual regional frequency of EMS calls for overdose (< 100, 100–200, > 200).
Barrington, Bristol, Burrillville, Central Falls, Charlestown, Coventry, Cumberland, East Greenwich, East Providence, Exeter, Glocester, Hopkinton, Jamestown, Johnston, Lincoln, Middletown, Narragansett, Newport, North Kingstown, North Providence, North Smithfield, Portsmouth, Richmond, Scituate, Smithfield, South Kingstown, Tiverton, Warren, other, and outside of Rhode Island.
Cranston, Pawtucket, Warwick, Woonsocket, and unknown.
Providence.
Specifically, patients treated at EDs with a regional frequency of more than 200 emergency medical services (EMS) calls for opioid overdose annually were 1.21 times more likely to receive take-home naloxone in the ED than those treated at EDs with a regional frequency of fewer than 100 opioid overdose EMS calls (95% confidence interval [CI] = 1.10, 1.33). Patients treated at level-1 EDs were 1.18 times more likely to receive take-home naloxone than those at level-3 EDs (95% CI = 1.05, 1.33). Finally, patients who were administered naloxone just before ED arrival were 1.29 times more likely to receive take-home naloxone in the ED than those who were not administered naloxone before ED presentation (95% CI = 1.14, 1.46).
There were no known adverse effects or unintended consequences attributable to implementation of the policy or distribution of take-home naloxone in Rhode Island EDs. However, there has not yet been a comprehensive evaluation of ED take-home naloxone receipt to measure its use or other individual outcomes. We identified factors associated with receipt of take-home naloxone at ED visits for opioid overdose in the context of a statewide mandate to offer naloxone to all opioid overdose patients at discharge. This evaluation suggests that additional implementation and training efforts are needed in EDs with a lower certification level (level 3) and in areas that receive fewer than 100 EMS calls for opioid overdose annually. In areas where overdose is treated less frequently, more education and risk awareness are needed among both providers and patients to increase naloxone receipt. Education should also emphasize identifying people at risk for overdose, which includes those who do not receive naloxone before ED arrival.
SUSTAINABILITY
Naloxone for ED distribution is currently purchased by individual hospitals and is not reimbursable, which raises a sustainability concern given rising costs of naloxone13 and insufficient access to naloxone in the community.14 Strategies to improve supply, reduce costs of naloxone, and establish insurance reimbursements for naloxone distribution are needed.
PUBLIC HEALTH SIGNIFICANCE
Rhode Island’s statewide treatment standards for postoverdose care in EDs aim to improve naloxone access among people at high risk of opioid overdose, with the goal of preventing opioid overdose‒related deaths. There are opportunities to improve ED naloxone provision in areas with lower overdose incidence and in EDs with less-comprehensive overdose treatment protocols. Establishing and maintaining a high level of ED naloxone distribution may help to close the naloxone access gaps when community supply is constrained.
ACKNOWLEDGMENTS
This study was funded by the Centers for Disease Control and Prevention (grants R01CE003149 and NU17CE924967). E. A. Samuels was partially supported by the National Institutes of Health (grants P20GM125507 and U54GM115677) and the Substance Abuse and Mental Health Serrvices Administration (grant UR1TI080209).
The authors would like to acknowledge and thank Jennifier Koziol, MPH, Rachel Scagos, MPH, and the Rhode Island Department of Health Overdose Prevention Program.
Note. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention, the National Institutes of Health, or the Substance Abuse and Mental Health Services Administration.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
This study was reviewed and approved by the Lifespan institutional review board.
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