Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

Abstract

Study objective: We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment.

Methods: A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation.

Results: We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Figure 1.

Analytic sample from Rhode Island Opioid Overdose Reporting System data, pre-Levels of Care (January–March 2017) and post-Levels of Care implementation (hospital certification date–December 2018).

Figure 2.. Interrupted time series of percentage of opioid overdose ED visits before and after levels of care certification in Rhode Island Opioid Overdose Reporting System, 2017–2018.

Week 0 is the first week the hospital was certified. Weeks < 0 are weeks prior to the announcement of the Levels of Care on March 31^st, 2017. The lines represent the linear trend for the time period before or after certification. Sample includes 1,575 suspected opioid overdose ED visits where the patient was discharged after seeing a provider in a Rhode Island ED (sample described in table 1, further limited to visits occurring from January-March 2017 and those occurring for up to 64 weeks after hospital certification). Figure notes: Behavioral counseling included behavioral counseling with a peer recovery coach, counselor, social worker, or psychiatrist. Treatment referrals included linkage to treatment by referral to outpatient services, admission to an inpatient program, referral to an outpatient Center of Excellence (COE) or medication for OUD (MOUD) provider.

Figure 2.. Interrupted time series of percentage of opioid overdose ED visits before and after levels of care certification in Rhode Island Opioid Overdose Reporting System, 2017–2018.

Week 0 is the first week the hospital was certified. Weeks < 0 are weeks prior to the announcement of the Levels of Care on March 31^st, 2017. The lines represent the linear trend for the time period before or after certification. Sample includes 1,575 suspected opioid overdose ED visits where the patient was discharged after seeing a provider in a Rhode Island ED (sample described in table 1, further limited to visits occurring from January-March 2017 and those occurring for up to 64 weeks after hospital certification). Figure notes: Behavioral counseling included behavioral counseling with a peer recovery coach, counselor, social worker, or psychiatrist. Treatment referrals included linkage to treatment by referral to outpatient services, admission to an inpatient program, referral to an outpatient Center of Excellence (COE) or medication for OUD (MOUD) provider.

Figure 2.. Interrupted time series of percentage of opioid overdose ED visits before and after levels of care certification in Rhode Island Opioid Overdose Reporting System, 2017–2018.

Week 0 is the first week the hospital was certified. Weeks < 0 are weeks prior to the announcement of the Levels of Care on March 31^st, 2017. The lines represent the linear trend for the time period before or after certification. Sample includes 1,575 suspected opioid overdose ED visits where the patient was discharged after seeing a provider in a Rhode Island ED (sample described in table 1, further limited to visits occurring from January-March 2017 and those occurring for up to 64 weeks after hospital certification). Figure notes: Behavioral counseling included behavioral counseling with a peer recovery coach, counselor, social worker, or psychiatrist. Treatment referrals included linkage to treatment by referral to outpatient services, admission to an inpatient program, referral to an outpatient Center of Excellence (COE) or medication for OUD (MOUD) provider.

Figure 3.. Percentage^a of visits offered and receiving services before and after Levels of Care hospital certification by Level of Certification, 2017-2018.

Behavioral counseling included behavioral counseling with a peer recovery coach, counselor, social worker, or psychiatrist. Treatment referrals included linkage to treatment by referral to outpatient services, admission to an inpatient program, referral to an outpatient Center of Excellence (COE), or medication for OUD (MOUD) provider. ^a Percentage of visits where services were offered and received before after levels of care certification, total and by level of certification. Sample is 1,585 ED visits by patients discharged after seeing a provider in a Rhode Island ED for an opioid overdose from January to March, 2017 and the date of hospital certification through December 2018.