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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: Acad Emerg Med. 2021 Feb 28;28(5):542–552. doi: 10.1111/acem.14197

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

Kathryn Hawk 1, Lauretta E Grau 2, David A Fiellin 1,3, Marek Chawarski 4, Patrick G O’Connor 3, Nikolas Cirillo 1,5, Chris Breen 1,6, Gail D’Onofrio 1,2
PMCID: PMC8281441  NIHMSID: NIHMS1703264  PMID: 33346926

Abstract

Objective:

Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence-based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients’ perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post–opioid overdose period.

Methods:

We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural).

Results:

The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self-reported lifetime opioid overdoses. Eight themes were identified as influencing participants’ consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs.

Conclusions:

Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED-based research evaluating a patient-oriented approach to engage patients after opioid overdose.

INTRODUCTION

Opioid use disorder (OUD) has a high morbidity and mortality, with more than 50,000 opioid overdose deaths in 2019 in the United States, an increase of more than 30% since 2015.1,2 OUD treatment with methadone or buprenorphine has been associated with positive outcomes for patients including enhanced substance use treatment retention, reductions in nonmedical opioid use, and lower incidence of infectious complications (e.g., HIV, hepatitis C), overdose, and mortality.3–15 One-year mortality for emergency department (ED) patients following a visit for nonfatal opioid overdose is 4.7% to 5.5%, and recent ED visits for opioid overdose have been identified as a strong predictor of subsequent fatal overdose.16–20 Effective linkage to medications for the treatment for OUD (MOUD) following overdose is rare, with only 8% of individuals receiving methadone and 13% receiving buprenorphine in the year following an ED visit for nonfatal opioid overdose.20–22 In part, this is due to the absence of evidence-based protocols and guidelines for the ED care after nonfatal opioid overdose and a limited understanding of goals and perceived needs of ED patients after opioid overdose.23–26

The transtheoretical model, also known as the Stages of Change, describes changes in health behavior as a progression through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination.27,28 The importance of understanding individual readiness to change is critical to the effective enhancement of motivation to change and is the foundation of motivational interview-based interventions.29,30 Promising intervention components to improve outcomes in ED patients with acute opioid overdose include naloxone distribution, motivational interview–based interventions, peer navigators, and initiation or linkage to MOUD, although outcome data are mixed, underpowered, and largely retrospective in ED patients with acute overdose.31–35 A landmark study comparing patients who began buprenorphine during an ED visit to those randomized to receive a standard or facilitated referral found that patients with ED-initiated buprenorphine and primary care follow-up for ongoing buprenorphine were twice as likely (78% vs. 35%) to be engaged in addiction treatment at 30 days, although only 9% of study participants were enrolled following an opioid overdose.35 To date, no randomized controlled trials have identified effective strategies to improve outcomes in ED patients following opioid overdose with MOUD initiation, a key strategy to reduce opioid-associated morbidity and mortality.24,29,36

Although much is known about improved outcomes of individuals with OUD engaged in MOUD, the perspectives of ED patients on their needs and the potential role of the ED in meeting those needs in the ED following an opioid overdose has been inadequately explored and is critical to developing patient-centered interventions. Closing this knowledge gap is critical, because ED clinicians often report patients seeking care after an overdose as uniquely challenging to engage in treatment discussions and often interpret patient behaviors as disinterest in ED-based intervention.24,37 Qualitative studies are best suited to generate in-depth understanding of the complex factors that may impact patients’ choice to accept referral for treatment or other services or to initiate MOUD treatment in the ED.25 As the first step to inform development of an ED-based intervention, the current study sought to explore how ED patients’ personal goals and perceived resource needs may shape patient priorities and decisions to engage with treatment and other patient support services.

METHODS

Study design and setting

We administered a brief quantitative survey and conducted semistructured qualitative interviews with adult ED patients receiving care after an acute opioid overdose in a large, urban, academic ED in Connecticut where the 2017 state opioid overdose fatality rate was 30.7 per 100,000 population, ranking 10th nationally.38 This study was approved by the institutional review board (IRB) at Yale University. The Standards for Reporting Qualitative Research (SRQR) were used to guide study reporting.39

Selection of participants

Emergency department patients were eligible for the study if they: (1) had experienced an opioid overdose immediately prior to ED arrival, (2) were not suicidal, (3) were not anticipated to require hospital admission, (4) were not currently receiving MOUD, (5) spoke English, and (6) were able to provide informed consent. Recruitment took place during rotating evening and day schedules. Potential participants were identified based on screening by electronic medical record or ED treatment team referral, if they had no preexisting relationship with any of the researchers, or if they were not under the care of the researchers at time of enrollment. As part of the consent process, participants were informed that all questions were voluntary, and that if they did not wish to discuss any particular topic, they could abstain from responding and/or end the interview at any time. Two patients declined participation because of a lack of interest in research (n = 1) and a concern that participation may delay ED discharge (n = 1). All other participants approached who met criteria were enrolled. Participants received a $25 gift card after completing the interview.

Data collection and interview procedures

Prior to the semistructured interview, a research assistant administered a brief quantitative survey designed by the research team for this study to collect demographic information (sex, age, race), history of substances consumed within the 24 hours prior to overdose, and lifetime number of opioid overdoses. The Mini International Neuropsychiatric Interview (MINI) Structured Clinical Interview for DSM-IV (SCID), a validated assessment for DSM-IV opioid dependence, was also administered.40 The MINI-SCID DSM-IV was selected because at the time of IRB approval, a validated DSM-5 structured questionnaire for OUD was not available. Most interviews (n = 22) occurred in the ED during the index overdose visit; one participant returned 2 days later to complete the interview, and another began the interview in the ED but ultimately required admission and the interview was completed as an inpatient. Interviews lasted a mean of 18.9 minutes, with a median (IQR) of 19.4 (6.75) minutes.

Enrollment and interviews were conducted by an emergency medicine physician (K.H.) with formal training in qualitative methods and expertise in addiction research, a psychology student (N.C.), or a medical student (C.B.) under the supervision of the first author. The interview guide (Figure 1) was developed by the research team specifically for this study and included five primary domains: (1) most recent overdose, (2) overdose and substance use treatment history, (3) overdose knowledge, (4) patterns of substance use, and (5) perceived needs. The interview guide was grounded in concepts from the literature and the clinical experience of researchers in caring for ED patients after opioid overdose. The application of specific prompts from the interview guide within each domain evolved over the course of the study as new concepts emerged from the data, but it was not formally pilot tested.41 All interviews were audio-recorded and transcribed verbatim.

FIGURE 1.

FIGURE 1

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Semistructured interview guide

Data analysis

Descriptive statistics of the study sample were calculated using STATA version 13.1. The transcripts were entered into ATLAS.ti (Version 8.0), and using thematic analysis and constant comparison methods,42–44 common patterns were identified within the data and organized into themes. We allowed new codes and themes to emerge organically from the text in the tradition of grounded theory.41 All transcripts were coded independently by both the first author (K.H.) and a clinical psychologist with expertise in qualitative methods and substance use research (L.E.G.). They met regularly to iteratively develop the codebook, to resolve any coding discrepancies, and to analyze and organize the data into themes. The finalized codebook included 35 codes across the five domains. Consistent with best practices in qualitative research, an audit trail was maintained including field notes taken after each interview as well as notes about the individually coded transcripts, coding discrepancies, and codebook revisions.42,45 Interviews continued until data saturation had been achieved. Analysis started in September 2016 and was concluded in August 2020. To preserve anonymity, participant quotes are identified by a participant number, sex, and age by decade.

Our identified themes highlighted the complex interplay between individual, relationship, community, and societal factors, making Bronfenbrenner’s Social Ecological Model a natural fit for our data.46,47 Themes that emerged from the data were organized into a modified version of Bronfenbrenner’s Social Ecological Model.46,47 Individual-level themes focused on concepts and experiences that are internal to the participant and shape an individual’s consideration of substance use treatment following an opioid overdose. The interpersonal level focused on the individual’s interaction with others (i.e., family, friends, and treatment or health care providers). The organizational-level identified themes concerning the overdose response system including emergency medical services (EMS), the ED, and the substance use treatment system. The structural level focused on policies that can shape entry into MOUD treatment and housing supports.

RESULTS

Characteristics of study participants

All participants were interviewed between June 2016 and August 2017. As noted in Table 1, the sample included 24 participants whose mean (±SD) age was 33 (±9.33) years. The majority were male (16/24; 67%) and White (20/24; 83%) and met DSM-IV criteria for opioid dependence (20/24; 83%). The mean (±SD) number of self-reported lifetime opioid overdoses was 3.25 (±2.64). Most participants (23/24) identified heroin as their opioid of choice; one participant preferred oxycodone. All reported having used what they believed to be heroin prior to the index overdose, and all were willing to discuss items from all five domains of the interview guide, including perceived overall and treatment needs. Participants described factors associated with an increased risk of opioid overdose including recent incarceration (i.e., jail, lockup, or prison) within the past several months (n = 4), recent tapering of methadone treatment (n = 1), and discharge from inpatient or residential non-MOUD treatment (n = 2). Co-ingestion of benzodiazepines and/or alcohol was common (12/24; 50%). Eighteen of the 24 participants reported prior substance use treatment experience. Almost all participants identified a need or desire to stop using drugs. No differences by age or sex were noted in the themes expressed.

TABLE 1.

Participant characteristics

Participant characteristics Mean (±SD) or n (%)
Age (years), mean (±SD) 33.5 (±9.33)
 Range 22–56
Male 16/24 (67)
Race/ethnicity
 White 20/24 (83.3)
 Black 3/24 (12)
 Hispanic 1/24 (4.3)
DSM-4 opioid dependence 20/24 (83.3)
Reported lifetime overdoses 3.25 (±2.64)
 Range 1–10
Reported heroin use at most recent overdose 100%
Past SUD treatment experiencea
 “Detox/Rehab” 9
 Methadone 12
 Buprenorphine 1
 No prior treatment 5
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a

Patient reported. Not mutually exclusive.

Results of the thematic analysis

Eight themes were identified across the four levels of the modified Social Ecological Model (Figure 2). At the individual level, two themes emerged. The first pertained to perceptions of personal control over drug use and the second focused on personal experiences with substance use treatment. The interpersonal level included two themes: role of interpersonal relationships and interpersonal communication. The organizational level included the themes of stigma and ED resources. The structural level themes were treatment policies and housing and basic needs support.

FIGURE 2.

FIGURE 2

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Themes organized by a modified Social Ecological Model

Theme 1: Perceptions about personal control over drug use (individual level)

Participants reported a wide variation in perceptions about ability to control future drug use, with many participants being highly confident, while some had little confidence or felt that they were subject to factors beyond their control. The confident participants often minimized current drug use problems or asserted they would be able to stop using drugs without seeking or engaging in treatment. Several participants opined that personal resolve was more important than engaging in treatment:

I need to man up. I need to do what I need to do to keep myself clean and stop trying to kid myself into believing that I could have my cake and eat it too.

(Participant #3, male, 40s)

One participant described the internal tension between needing assistance to control drug use and a belief in her own personal control:

The problem with me and I think most addicts is that they we convince ourselves we can do it on our own and we don’t need other people to help us … I know where my resources are. I guess you can say because I’ve been to so many treatment centers.

(Participant #2, female, 20s)

Other participants sought to minimize their drug use problem and attributed the overdose to bad luck or factors beyond their control such as adulterated drugs.

If I was worse off than what I am now, I would gladly accept help. But I’m not that bad. I’ve done probably like four bags of heroin in the last month. It just happened to be a bad batch.

(Participant #19, female, 20s).

Participants who doubted their ability to change their drug use noted feeling helpless when confronting the disease of addiction or the social and environmental challenges they often faced.

Some people think you can just stop. It’s bullshit. You can’t just stop. If you could just stop, I think all addicts would’ve just stopped by now.

(Participant #23, male, 20s).

Theme 2: Experience with substance use treatment (individual level)

Most participants had prior treatment experiences that influenced their opinions about treatment effectiveness and their consideration of engaging with treatment. Overall, participants appeared to believe that treatment was generally ineffective or with limited sustainable impact on drug use postdischarge.

I’ve been to outpatient programs and had no luck. Like I just, being in a room full of people talking about doing drugs makes me want to go out and do drugs. And that’s always been my problem.

(Participant #4, female, 30s).

Yes, it has somewhat [been helpful in the past]. I’ve stayed clean for a while but then I always end up going back to it.

(Participant #22, male, 40s).

Participants with prior experience with methadone were often not interested in reengaging with methadone treatment for reasons such as the inconvenience of attending clinic daily or medication side effects. By contrast, those who reported prior treatment experiences that were positive appeared to be more receptive to the idea of returning to treatment.

I feel like the methadone is just like with handcuffs and I’m so sick of being dragged down by something.

(Participant #19, female, 20s)

[Methadone] didn’t work out for me though. It was like, you know, some people do really good on it … It just had a weird effect on me. It made me like lethargic.

(Participant #12, male, 40s)

I got on Suboxone, and that worked well. It worked well for a while. Probably, probably a good four years I did, I did well on that, and that’s why I was thinking that I wanted to get back on it.

(Participant #17, male, 50s)

Theme 3: Role of interpersonal relationships (interpersonal level)

This theme refers to important social relationships with family and friends and can either pose barriers to or facilitate ED patients’ motivation to enter MOUD. It was often acknowledged as a major reason for participants’ consideration of treatment and underscored the importance that family could have for some patients. Participants described their anger and shame in having overdosed in terms of the potential consequences it could have had for their families. The relationships with friends and family imparted a sense of meaning to life, a connection to others, and a reason to live.

I’m angry with myself. I almost lost my life today. I almost left my child without a father and my girlfriend without a partner. It was different when I overdosed and I was single and I was in the life and I was a daily user and I didn’t really care.

(Participant #25, male, 30s)

I was in my son’s house with my granddaughter. So I’m kind of disgusted with myself … I love that little girl.

(Participant #12, male, 40s)

By contrast, others were acutely aware of lacking a sense of connection to others, projecting an overwhelming sense of alienation and isolation that seemed to suggest that entering treatment would be pointless:

I just don’t have anybody. Feels like I’m like the only person alive on this earth. There’re trillions of people here, and no one understands me at all. I definitely feel alone … I don’t have any family, I don’t have any friends, so I do heroin. And that’s my friend.

(Participant #3, male, 20s)

Theme 4: Provider communication skills (interpersonal level)

Participants spoke of how their sense of personal shame, guilt, or anger with having overdosed could be exacerbated by negative interpersonal interactions with first responders or ED staff. These interactions left some participants feeling greatly diminished (e.g., that caring for patients after overdose was a waste of time) or objectified (e.g., an object of scorn).

I’m angry at how they treated me like shit they because I had drugs and I OD-ed, they figured … we should be dealing with people who have real problems, not some asshole overdosing.

(Participant #9, female, 40s)

I mean honestly the thing that bothers me is the looks … It’s like every nurse in the emergency room has to come and walk by me like “you’re the girl that overdosed” and it’s kind of like “she’s just a drug addict, so who cares.” I mean my specific nurse she’s very nice I’ve got nothing against her.

(Participant #2, female, 20s)

While some interactions were perceived to be negative, several participants reported that staff communication skills and understanding of emergency providers have improved over time. When asked how to further improve interactions in the ED, participants highlighted the importance of empathetic listening by ED staff.

For a long time, people didn’t want to talk about [overdose prevention and drug use], and now it’s not like that anymore, and I’m glad it’s not.

(Participant #25, male, 30s)

Putting yourself in somebody else’s shoes and see what works for them … This is helping.

(Participant #27, male, 20s)

Theme 5: Role of stigma (organizational level)

The ED was recognized as an important venue for medical care and access to services, but participants also noted that stigma posed a barrier to accessing emergency and health care services. Several participants acknowledged feeling ashamed about their overdose and how that shame can be exacerbated by feeling more visible and exposed in the ED, both figuratively and literally (i.e., in a hallway).

But it’s just like you can tell that [the ED nurses] all heard there was an overdose and they all wanted to come and see what I looked like you know and maybe that’s just me in my head thinking crazy but I get it. It just sucks you know, the stigma of addicts.

(Participant #2, female, 20s)

Participants often also described the impact of stigma surrounding OUD treatment itself and cited stigma associated with receiving treatment.

I didn’t want to go on methadone because it was just that stigma of going to methadone clinic and being stuck on it

(Participant #17, male, 50s)

Theme 6: The ED as a source of resources (organizational level)

In general, participants appeared convinced that the ED should provide resources and support following an opioid overdose. They recommended that the ED offer harm reduction resources such as naloxone distribution and education about overdose prevention.

The best thing [the ED] can do is just to make sure that people have access to Narcan and access to the things to make sure that people don’t die.

(Participant #26, male, 20s)

People are going to overdose. People are going to get sick. They’re going to have a bad reaction to whatever they took, and they’re going to end up [in the ED.]

(Participant #25, male, 30s)

Other participants focused on needing help to meet their basic needs, with some specifically suggesting that the ED may be able to facilitate referrals to housing, employment or mental health services. For example, when asked about specific things that the ED could do to help patients access needed resources, one participant offered:

Do you guys know of any lists of people hiring or anything like that? I think most important for me right now is to get a job because if I can get a job, then maybe I could get one of the services to help me find a place to live.

(Participant #20, female, 30s)

What I want is to magically have a job when I get out [of the hospital] so that I can actually get an apartment and just show everybody that I can go to work every day and do everything that I used to do.

(Participant #13, female, 30s)

Finding stable and permanent housing was a high priority for participants but could be a challenge for some. Several participants identified their housing situation (either homelessness or living in a house with active drug use) as a conduit to ongoing drug use.

Being around [my mom and brother] twenty-four/seven is not the greatest thing, [but] … it’s either do that or be homeless and … I’m obviously going to choose living under a roof instead of sleeping outside.

(Participant #18, male, 20s)

Theme 7: Impact of treatment policies theme (structural level)

Participants highlighted the challenging requirements for entry into substance use treatment, specifically as not being “sick enough” and primarily based on criteria concerning drug use patterns, withdrawal symptoms, or finances.

I’ve been turned away because I didn’t have physical signs or withdrawals. Mentally, I had problems but physically no, so they turned me away. Mentally it was, I want to do it more often, but I haven’t the money … but because I didn’t have physical symptoms of withdrawal, they told me no.

(Participant #4, female, 30s)

I never make it past the intake or processing because they’re like, “Wait, you’re not even sick enough”.

(Participant #16, Male, 20 s).

Theme 8: Support for unmet basic needs (structural level)

Unmet housing and basic needs such as employment and mental health care were key priorities for many participants, yet existing policies could pose serious barriers to accessing these needed resources. For example, participation in previous treatment programs or currently receiving MOUD treatment rendered some participants ineligible for supportive housing.

I’ve been in sober houses, inpatient programs, and a halfway house, stuff like that, it’s considered housed but it’s not permanent … I have to have chronic homelessness to get permanent supportive housing.

(Participant #13, female, 30s)

Some sober houses you can’t live in because you’re on suboxone or you’re on methadone.

(Participant #23, male, 20s)

Many participants noted ongoing mental health needs, most of whom were receiving care for ongoing depression or anxiety. A few were not currently in treatment, but felt that it was needed, as one participant explained:

I don’t need drug treatment; I just honestly need a therapist. And to get prescribed medicine.

(Participant #18, male, 20s)

No participant acknowledged the possibility that effective substance use disorder (SUD) treatment could lead to improvement in fulfilling housing, employment, or mental health needs. However, several did note that they believed that they could control their drug use by meeting housing, employment, or mental health needs.

The only way I’ll be able to control [my drug use] is run away from people and going to work and going home …I can’t be out in the streets, which is what I am all day, every day, because I have nowhere to go.

(Participant #20, female, 30s)

DISCUSSION

Our study identified themes that may help ED clinicians shape clinical care and design patient-centered ED interventions to promote engagement with treatment and other support services. Key themes include individuals’ perceived self-control over future drug use, the influence of previous SUD treatment experiences, the importance of interpersonal relationships and effective and sympathetic healthcare staff, the pervasive role of stigma, and a recognition that the ED could provide access to resources. Our work emphasizes that ED patients are willing to discuss OUD and treatment if approached in a nonjudgmental way and highlights several potential factors that may facilitate improved outcomes and treatment engagement such as enhancing patient control in the process, using a trauma-informed approach, reducing stigma by normalizing addiction as a medical disease, and improving the ability of the ED to refer patients to other resources that address complex unmet needs. The need for patients to feel that their providers care about their overall well-being is important and has been found to promote engagement for patients with OUD in treatment in a non-ED setting.48,49

Participants identified wanting to control or stop their drug use as a priority, and outwardly many expressed the belief that they had the ability to do so. ED clinicians should recognize and address that this may also represent a desire for control when patients do not feel much control. One strategy to enhance patient sense of control is to offer low-barrier access to buprenorphine for patients interested in a prescription for unobserved initiation. To maximize ongoing treatment with buprenorphine, both the access to initiation and the rapid transition to an outpatient treatment clinician that can provide ongoing care should be low-barrier and patient-centered. Linkage to ongoing care should ideally occur within a few days. Another strategy to enhance patient sense of control is to provide a safe, nonjudgmental space to discuss and provide needed resources, including overdose prevention education, naloxone, and referrals to resources for other unmet needs including housing. Several participants described experiencing stigma en route to and while receiving care in the ED, which is consistent with previous studies and highlights a critical need to educate and train ED and other health care providers about the negative impact of prior demoralizing, stigmatizing, and traumatic health care interactions experienced by individuals who use drugs.50–53

Our findings highlight a tension between what clinical experts believe is the most important factor in improving patient outcomes following an opioid overdose and what patients describe as their priorities in the acute-overdose period. Patients and providers are viewing likelihood of improved outcomes through different lenses. Several studies have demonstrated an improved quality of life for patients with OUD engaged with MOUD, who often have complex unmet needs including health, housing, and employment.48,54–57 Although the existence of complex needs of patients following an opioid overdose is not a novel finding, the degree to which unmet housing and employment needs outweigh the perceived need of SUD treatment, even in the aftermaths of an overdose, has not previously been demonstrated in ED patients. The burden of these unmet needs is consistent with, and in fact is the foundation of, Maslow’s Hierarchy of Needs, which should be considered in the development of future ED-based interventions.58,59 Participants also overwhelmingly reported both a desire and an intention to reduce future drug use, but none acknowledged the possibility that engagement with treatment could facilitate the meeting of these needs or improve their overall quality of life. Assistance in making these connections may enhance motivation to engage in OUD treatment by facilitating a shift in participants’ Stage of Change.

To our knowledge, this is the first study designed to understand the goals and perspectives of ED patients receiving medical care in the ED immediately following a nonfatal opioid overdose. Interventions that aim to increase treatment linkage for ED patients with OUD have used brief interventions to enhance motivation to initiate treatment with buprenorphine in the ED with close follow-up,34,35 but little is known about how to specifically enhance patient engagement immediately following opioid overdose.36 Overdose survivors are most often not seeking treatment and our findings suggest that the adaptation of a patient-centered intervention such as a Brief Negotiation Interview (BNI), for ED patients following overdose may enhance patient motivation and assist the patient in linkage to MOUD treatment or other needed resources. The BNI is a 5- to 10-minute guided discussion that incorporates feedback and advice to enhance patient motivation and assist the patient in making a positive change regarding substance use.60,61 The first step of a the BNI is to ask permission to discuss the patients’ use, which signals a respect for individual autonomy, followed by a discussion on use and its impact on the patients’ life and a guided discussion to enhance and explore his or her motivation to make a change that is grounded in the reasons provided by the patient to consider change (if any), followed by the negotiation of a concrete plan to act on the patients’ motivation.62,63

Future interventions should include strategies designed to enhance motivation to enter MOUD treatment, such as the BNI, and have referral pathways in place to address complex ongoing needs outside of the ED, while providing low-barrier access to buprenorphine when appropriate and outpatient follow-up. There is an urgent need to evaluate the above strategies combined with ED-based interventions focused specifically on overdose prevention64 to improve access to MOUD11,65,66 and naloxone.67–69

LIMITATIONS

While the qualitative data provide rich insight into the knowledge, experience, perceived needs, and goals of the 24 individuals who participated in the study, an inherent limitation is that, although we reached thematic saturation, a different set of themes may have emerged from different participants. Furthermore, all reported having used what they believed to be heroin (although the concurrent epidemiology in Connecticut supports high prevalence of fentanyl in the heroin supply), and the findings may not apply to those with overdoses involving prescription opioids, non-English speakers, individuals with different demographics, or those who refused to participate in the study. We chose to keep interviews as brief as possible based on clinical and logistic factors in the ED and believe that the extent to which participants had discussed their overdose and drug use with EMS, nursing, and clinicians allowed for fast rapport and the collection of rich qualitative data. Finally, social desirability and recall bias may have influenced the data collection. We attempted to minimize the former by excluding anyone who received direct patient care from one of our research investigators and the latter by conducting the interviews within a relatively short time after the overdose event.

CONCLUSION

Patients receiving ED care following overdose are willing to discuss their opioid use and substance use disorder treatment with ED providers but often have complex unmet needs. This research supports the development of a patient-centered ED-based intervention that includes provider education and stigma awareness training in addition to evaluating optimal strategies to address patient needs and decrease opioid-associated morbidity and mortality in the ED following a nonfatal opioid overdose.

Acknowledgments

Funding information

NIDA K12 DA033312, Emergency Medicine Foundation Pilot Grant

Footnotes

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

REFERENCES

  • 1.Ahmad F, Rossen L, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed July 16, 2020. [Google Scholar]
  • 2.US Department of Health and Human Services. CDC WONDER. 2018. https://wonder.cdc.gov/. Accessed June 16, 2019. [Google Scholar]
  • 3.Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;(3):CD002209. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Gibson A, Degenhardt L, Mattick RP, Ali R, White J, O’Brien S. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–468. [DOI] [PubMed] [Google Scholar]
  • 5.Schwartz RP, Jaffe JH, O’Grady KE, et al. Interim methadone treatment: Impact on arrests. Drug Alcohol Depend. 2009;103(3): 148–154. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Burns L, Mattick RP, Lim K, Wallace C. Methadone in pregnancy: Treatment retention and neonatal outcomes. Addiction. 2007;102(2):264–270. [DOI] [PubMed] [Google Scholar]
  • 7.Jones HE, O’Grady KE, Malfi D, Tuten M. Methadone maintenance vs. methadone taper during pregnancy: maternal and neonatal outcomes. Am J Addict. 2008;17(5):372–386. [DOI] [PubMed] [Google Scholar]
  • 8.Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet. 2003;361(9358):662–668. [DOI] [PubMed] [Google Scholar]
  • 9.Bruce RD. Methadone as HIV prevention: high volume methadone sites to decrease HIV incidence rates in resource limited settings. Int J Drug Policy. 2010;21(2):122–124. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Metzger DS, Woody GE, McLellan AT, et al. Human immunodeficiency virus seroconversion among intravenous drug users in- and out-of-treatment: an 18-month prospective follow-up. J Acquir Immune Defic Syndr. 1993;6(9):1049–1056. [PubMed] [Google Scholar]
  • 11.Ma J, Bao YP, Wang RJ, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. 2019;24(12):1868–1883. [DOI] [PubMed] [Google Scholar]
  • 12.Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv. 2014;65(2):158–170. [DOI] [PubMed] [Google Scholar]
  • 13.Molero Y, Zetterqvist J, Binswanger IA, Hellner C, Larsson H, Fazel S. Medications for alcohol and opioid use disorders and risk of suicidal behavior, accidental overdoses, and crime. Am J Psychiatry. 2018;175(10):970–978. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Evans EA, Zhu Y, Yoo C, Huang D, Hser Y. Criminal justice outcomes over 5 years after randomization to buprenorphine-nalox-one or methadone treatment for opioid use disorder. Addiction. 2019;114(8):1396–1404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Woody GE, Bruce D, Korthuis PT, et al. HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic Syndr. 2014;66(3):288–293. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: A systematic review. Am J Public Health 2014;104(8):e32–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Brady JE, DiMaggio CJ, Keyes KM, Doyle JJ, Richardson LD, Li G. Emergency department utilization and subsequent prescription drug overdose death. Ann Epidemiol. 2015;25(8):613–619. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital signs: Trends in emergency department visits for suspected opioid overdoses — United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep. 2018;67(9):279–285. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Weiner SG, Baker O, Bernson D, Schuur JD. One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Ann Emerg Med. 2020;75(1):13–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality. Ann Intern Med. 2018;169(3):137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Williams AR, Nunes EV, Bisaga A, Levin FR, Olfson M. Development of a cascade of care for responding to the opioid epidemic. Am J Drug Alcohol Abuse. 2019;45(1):1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Martin A, Kunzler N, Nakagawa J, et al. Get waivered: a resident-driven campaign to address the opioid overdose crisis. Ann Emerg Med. 2019;74(5):691–696. [DOI] [PubMed] [Google Scholar]
  • 24.D’Onofrio G, McCormack RP, Hawk K. Emergency departments — A 24/7/365 option for combating the opioid crisis. N Engl J Med. 2018;379(26):2487–2490. [DOI] [PubMed] [Google Scholar]
  • 25.Samuels EA, Dwyer K, Mello MJ, Baird J, Kellogg A, Bernstein E. Emergency department-based opioid harm reduction: Moving physicians from willing to doing. Acad Emerg Med. 2016;23(4):455–465. [DOI] [PubMed] [Google Scholar]
  • 26.Samuels EA, D’Onofrio G, Huntley K, et al. A quality framework for emergency department treatment of opioid use disorder. Ann Emerg Med. 2019;73(3):237–247. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51(3):390–395. [DOI] [PubMed] [Google Scholar]
  • 28.Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38–48. [DOI] [PubMed] [Google Scholar]
  • 29.Carroll JJ, Green TC, Noonan RK. Evidence-based strategies for preventing opioid overdose: what’s working in the United States An introduction for public heath, law enforcement, local organizations, and others striving to serve their community. Atlanta, GA: Centers for Disease Control and Prevention, 2018. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf. Accessed January 12, 2021. [Google Scholar]
  • 30.Littell JH, Girvin H. Stages of change. A critique. Behav Modif. 2002;26(2):223–273. [DOI] [PubMed] [Google Scholar]
  • 31.Papp J, Vallabhaneni M, Morales A, Schrock JW. Take-home naloxone rescue kits following heroin overdose in the emergency department to prevent opioid overdose related repeat emergency department visits, hospitalization and death- a pilot study. BMC Health Serv Res. 2019;19(1):957. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Banta-Green CJ, Coffin PO, Merrill JO, et al. Impacts of an opioid overdose prevention intervention delivered subsequent to acute care. Inj Prev. 2019;25(3):191–198. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Samuels EA, Bernstein SL, Marshall BD, Krieger M, Baird J, Mello MJ. Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes. J Subst Abuse Treat. 2018;94:29–34. [DOI] [PubMed] [Google Scholar]
  • 34.Bohnert AS, Bonar EE, Cunningham R, et al. A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose. Drug Alcohol Depend. 2016;163:40–47. [DOI] [PubMed] [Google Scholar]
  • 35.D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636–1644. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Bagley SM, Schoenberger SF, Waye KM, Walley AY. A scoping review of post opioid-overdose interventions. Prev Med (Baltimore). 2019;128:105813. [DOI] [PubMed] [Google Scholar]
  • 37.Elliott L, Bennett AS, Wolfson-Stofko B. Life after opioid-involved overdose: Survivor narratives and their implications for ER/ED interventions. Addiction 2019;114(8):1379–1386. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Centers for Disease Control and Prevention. Drug overdose mortality by state. https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.
  • 39.O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research. Acad Med. 2014;89(9): 1245–1251. [DOI] [PubMed] [Google Scholar]
  • 40.American Psychiatric Association, American Psychiatric Association. Task Force on DSM-IV. Diagnostic and statistical manual of mental disorders: DSM-IV. Philadelphia, PA: American Psychiatric Association, 1994. [Google Scholar]
  • 41.Corbin J, Strauss A. Basics of qualitative research: Techniques and procedures for developing grounded theory. 4th ed. Thousand Oaks, CA: Sage Publications, 2015:7–8. [Google Scholar]
  • 42.Patton MQ, Schwandt TA. Qualitative research & evaluation methods: Integrating theory and practice. 4th ed. Thousand Oaks, CA: Sage Publications, 2014. [Google Scholar]
  • 43.Clarke V, Braun V. Successful qualitative research: A practical guide for beginners. Thousand Oaks, CA: Sage Publications, 2013:28–29. [Google Scholar]
  • 44.Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. [Google Scholar]
  • 45.Ranney ML, Meisel ZF, Choo EK, Garro AC, Sasson C, Morrow GK. Interview-based qualitative research in emergency care part II: data collection, analysis and results reporting. Acad Emerg Med. 2015;22(9):1103–1112. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Bronfenbrenner U Toward an experimental ecology of human development. Am Psychol. 1977;32(7):513–531. [Google Scholar]
  • 47.Bronfenbrenner U Ecology of the family as a context for human development: Research perspectives. Dev Psychol. 1986;22(6):723–742. [Google Scholar]
  • 48.Korthuis PT, Tozzi MJ, Nandi V, et al. Improved quality of life for opioid-dependent patients receiving buprenorphine treatment in HIV clinics. J Acquir Immune Defic Syndr. 2011;56:S39–S45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Marchand K, Beaumont S, Westfall J, et al. Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review. Subst Abuse Treat Prev Policy. 2019;14(1):37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Browne T, Priester MA, Clone S, Iachini A, DeHart D, Hock R. Barriers and facilitators to substance use treatment in the rural south: a qualitative study. J Rural Heal. 2016;32(1):92–101. [DOI] [PubMed] [Google Scholar]
  • 51.Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018;57:104–110. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Earnshaw V, Smith L, Copenhaver M. Drug addiction stigma in the context of methadone maintenance therapy: an investigation into understudied sources of stigma. Int J Ment Health Addict. 2013;11(1):110–122. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Simon R, Snow R, Wakeman S. Understanding why patients with substance use disorders leave the hospital against medical advice: a qualitative study. Subst Abus. 2020;41(4):519–525. [DOI] [PubMed] [Google Scholar]
  • 54.Mitchell SG, Gryczynski J, Schwartz RP, et al. Changes in quality of life following buprenorphine treatment: Relationship with treatment retention and illicit opioid use. J Psychoactive Drugs. 2015;47(2):149–157. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Maremmani I, Pani PP, Pacini M, Perugi G. Substance use and quality of life over 12 months among buprenorphine maintenance-treated and methadone maintenance-treated heroin-addicted patients. J Subst Abuse Treat. 2007;33(1):91–98. [DOI] [PubMed] [Google Scholar]
  • 56.Winograd RP, Wood CA, Stringfellow EJ, et al. Implementation and evaluation of Missouri’s Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs. J Subst Abuse Treat. 2020;108:55–64. [DOI] [PubMed] [Google Scholar]
  • 57.Winograd RP, Presnall N, Stringfellow E, et al. The case for a medication first approach to the treatment of opioid use disorder. Am J Drug Alcohol Abuse. 2019;45(4):333–340. [DOI] [PubMed] [Google Scholar]
  • 58.Maslow AH. A theory of human motivation. Psychol Rev. 1943;50(4):370–396. [Google Scholar]
  • 59.Taormina RJ, Gao JH. Maslow and the motivation hierarchy: measuring satisfaction of the needs. Am J Psychol. 2013;126(2):155. [DOI] [PubMed] [Google Scholar]
  • 60.D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’Connor PG. Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med. 2005;12(3):249–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.D’Onofrio G, Fiellin DA, Pantalon MV, et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Ann Emerg Med. 2012;60(2):181–192. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.D’Onofrio G, Pantalon MV, Degutis LC, Fiellin DA, O’Connor PG. Development and implementation of an emergency practitioner-performed brief intervention for hazardous and harmful drinkers in the emergency department. Acad Emerg Med. 2005;12(3):249–256. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.D’Onofrio G, Degutis LC. Integrating Project ASSERT: a screening, intervention, and referral to treatment program for unhealthy alcohol and drug use into an urban emergency department. Acad Emerg Med. 2010;17(8):903–911. [DOI] [PubMed] [Google Scholar]
  • 64.Samuels E Emergency department naloxone distribution: a Rhode Island department of health, recovery community, and emergency department partnership to reduce opioid overdose deaths. R I Med J. (2013) 2014;97(10):38–39. [PubMed] [Google Scholar]
  • 65.Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014;(2):CD002207. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. Am J Public Health. 2013;103(5):917–922. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1–9. [DOI] [PubMed] [Google Scholar]
  • 69.McDonald R, Strang J. Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction. 2016;111(7):1177–1187. [DOI] [PMC free article] [PubMed] [Google Scholar]

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