People who have already suffered a nonfatal overdose should be prioritized in receiving evidence-based care to reduce subsequent risk, but far too often this isn’t happening, shows new research.
The study, led by Dr. Christopher Jones, director of the federal Center for Substance Abuse Prevention under the Substance Abuse and Mental Health Services Administration (SAMHSA), was published in the Journal of the American Medical Association on June 17. It investigated how often Medicare recipients who had suffered a nonfatal overdose subsequently received medications for opioid use disorder (MOUD), naloxone or other resources. The findings were troubling.
“Many patients treated for a drug overdose do not receive evidence-based services after their overdose.”
“Prior nonfatal drug overdose is an important factor in subsequent nonfatal and fatal drug overdoses,” the authors wrote. “Yet, many patients treated for a drug overdose do not receive evidence-based services after their overdose.”
The researchers looked at a group of over 136,000 people on Medicare who experienced a nonfatal overdose in 2020, a year when the dynamics of the overdose crisis and health care services were deeply impacted by COVID-19. The group had a mean age of about 68, and about 58 percent were women. By race and ethnicity, the group was about 6 percent Hispanic, 11 percent Black and 79 percent white. A large majority (79 percent) lived in urban areas.
Within one year of overdosing in 2020, over 17 percent of the group suffered a second overdose, and 1 percent died of overdose. Opioids were involved in over 72 percent of fatal overdoses.
An opioid-involved overdose does not necessarily mean that the person is experiencing opioid use disorder. Yet the likelihood of people receiving MOUD like methadone and Suboxone was strikingly low: Just 4 percent received such treatment in the 12 months following an overdose. And just 6 percent filled a prescription for naloxone, the opioid-overdose reversal drug. (A SAMHSA spokesperson clarified to Filter that the relevant billing data only captured paid claims, not information on prescriptions that were written but never filled.)
Unspurprisingly, given the weight of evidence behind these medications, the researchers found that receiving them—as well as receiving behavioral health assessments or crisis services—“were all associated with reduced adjusted odds of fatal drug overdose in the 12 months after the index nonfatal drug overdose.”
The obvious message, as the researchers concluded, is that much better access to these resources is needed amid the ongoing overdose crisis.
Sheila Vakharia, deputy director of research and academic engagement for the Drug Policy Alliance, said the study is quantifiable proof that the medical system is failing too many people at risk of overdose by not getting them simple interventions that can save lives.
“Using Medicare data tells us that medically vulnerable people, maybe older adults, who had a recent overdose, were being triaged in the hospital,” Dr. Vakharia told Filter, “but this person was sent back into the community and left to their own devices.”
“How do we help this big chunk of people who have experienced a nonfatal overdose? It sounds like for the majority of people in this study, that was a missed opportunity.”
Nationwide, a projected 107,543 people died of overdose in 2023. But this number, Vakharia noted, can make us forget the larger number of people who survive an overdose, for whom it’s not too late to intervene.
“How do we help this big chunk of people who have experienced a nonfatal overdose who woke up, and ended up in the hospital, and now, we know, have an increased risk of overdosing again?” she asked. “It sounds like for the majority of people in this study, that was a missed opportunity.”
The opportunity for hospitals and other health care providers to do better starts as soon as a patient comes through the door, Vakharia continued. As an example, she highlighted the Relay program in New York City, launched in 2017 to bring overdose prevention into hospitals and connect people directly with resources post-overdose. “I think more programs like Relay need to be developed in hospital systems around the country.”
The new study, she said, shows that when you rely on prescribing people naloxone and asking them to go somewhere else to get it, many people will not do so.
Relay cuts through this barrier, as a past study of the program illustrated, by just handing out free naloxone, alongside other elements of support like overdose education and referrals to harm reduction services, OUD medication treatment and other substance use disorder treatment. Over half of participants had not previously received a naloxone kit.
“You just need to hand people naloxone, don’t create another hoop for them to jump through.”
“Giving someone a prescription for naloxone and expecting them to go and fill it is different than handing it to them when they get out the door,” Vakharia said. “You just need to hand people naloxone, don’t create another hoop for them to jump through.”
The SAMHSA spokesperson told Filter that the Centers for Medicare & Medicaid Services behavioral health strategy includes support for community-based mobile crisis intervention services, increased telehealth services through Medicare including MOUD initiation, and expanding access to behaviorial health services.
“SAMHSA is working to increase access to MOUD as well as access to opioid overdose reversal medications such as naloxone for the public at large,” added Dr. Jones, the lead author of the new study, in a statement provided to Filter. “Earlier this year, SAMHSA published the first updates to opioid treatment program (OTP) regulations in over two decades. These changes make it easier for people to access MOUD and give providers the flexibility to provide case based on their clinical judgement.”
“Additionally, SAMHSA continues to provide Tribes, states, and territories with funding to increase access to care through the State Opioid Response and Tribal Opioid Response grants, among other SAMHSA funding to states and communities,” he continued. “Finally, SAMHSA has been working with states across the country to develop and implement naloxone saturation plans.”
The study authors acknowledged limitations including that they only looked at Medicare recipients—outcomes could differ significantly if people without insurance, Medicaid recipients and people on private health insurance were included. Jones noted, however, that “Our study also had a high percentage (approximately 44 percent) of beneficiaries that had Medicaid in addition to Medicare [and] were eligible for Medicare due to disability (approximately 28 percent)—both factors associated with increased risk for overdose.”
The study might also under-count overdose cases, as well as diagnoses of substance use disorder and other health information, because of its reliance on Medicare insurance coding.
“Although prior studies provide insights into the risks for subsequent drug overdose after a nonfatal overdose as well as missed opportunities to leverage nonfatal overdose as a critical intervention point, these studies typically were limited,” the authors wrote. “Thus, research using more recent data to account for new policies, care disruptions, and changing health system dynamics during the COVID-19 pandemic, as well as the increasingly toxic drug supply, is essential to inform policymaking.”
Photograph by M via Flickr/Creative Commons 2.0
The Influence Foundation, which operates Filter, previously received a restricted grant from the Drug Policy Alliance. Dr. Vakharia is a member of the board of directors of The Influence Foundation.
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