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Characteristics and Receipt of Medication Treatment Among Young Adults Who Experience a Nonfatal Opioid-Related Overdose

      Study objective

      Nonfatal opioid overdose represents an opportunity to engage young adults into using medication for opioid use disorder. We seek to describe characteristics of young adults who experience nonfatal overdose and estimate rates of and time to medication for opioid use disorder for young adults relative to those aged 26 to 45 years.

      Methods

      We conducted a cohort study using retrospective administrative data of 15,281 individuals aged 18 to 45 years who survived an opioid-related overdose in Massachusetts between 2012 and 2014, using deidentified, individual-level, linked data sets from Massachusetts government agencies. We described patient characteristics stratified by age (18 to 21, 22 to 25, and 26 to 45 years) and evaluated multivariable Cox proportional hazards models to compare rates of medication for opioid use disorder receipt, controlling for age, sex, history of mental health disorders, and addiction treatment.

      Results

      Among 4,268 young adults in the year after nonfatal overdose, 28% (n=336/1,209) of those aged 18 to 21, 36% (n=1,097/3,059) of those aged 22 to 25 years, and 36% (n=3,916/11,013) of those aged 26 to 45 years received medication for opioid use disorder. For individuals aged 18 to 21 and 22 to 25 years, median time to buprenorphine treatment was 4 months (interquartile range 1.7 to 1.8 months); to methadone treatment, 4 months (interquartile range 2.8 to 2.9 months); and to naltrexone treatment, 1 month (interquartile range 1 to 1 month). Individuals aged 18 to 21 years were less likely (adjusted hazard ratio 0.60 [95% confidence interval 0.45 to 0.70]) to receive methadone than those aged 22 to 25 and 26 to 45 years. Individuals aged 18 to 21 years and those aged 22 to 25 years were more likely to receive naltrexone (adjusted hazard ratio 1.65 [95% confidence interval 1.36 to 2.00] and 1.41 [95% confidence interval 1.23 to 1.61], respectively) than those aged 26 to 45 years.

      Conclusion

      One in 3 young adults received medication for opioid use disorder in the 12 months after surviving an overdose. Type of medication for opioid use disorder received appeared to be age associated. Future research should focus on how medication choice is made and how to optimize the emergency department for medication for opioid use disorder initiation after nonfatal overdose.

      Introduction

       Background

      In the United States, the age-adjusted opioid-related mortality rate tripled from 1999 to 2016.
      • Hedegaard H.
      • Miniño A.M.
      • Warner M.
      Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329.
      In Massachusetts, an alarming increase in opioid-related deaths occurred, from 379 in 2000 to an estimated 2,149 in 2016, which disproportionately occurred among individuals younger than 25 years.
      Massachusetts Department of Public Health
      Data brief: opioid-related overdose deaths among Massachusetts residents (2018-11).
      Young adults (aged 18 to 25 years) have been particularly affected by the opioid epidemic.
      • Martins S.S.
      • Sarvet A.
      • Santaella-Tenorio J.
      • et al.
      Changes in US lifetime heroin use and heroin use disorder: prevalence from the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions.
      Centers for Disease Control and Prevention
      Today’s heroin epidemic.
      • Jones C.M.
      The paradox of decreasing nonmedical opioid analgesic use and increasing abuse or dependence: an assessment of demographic and substance use trends, United States, 2003-2014.
      In the United States between 2002 and 2013, young adults had a greater increase in prevalence of past-year heroin use disorder (108%) compared with other age groups.
      • Jones C.M.
      • Logan J.
      • Gladden M.
      • et al.
      Vital signs: demographic and substance use trends among heroin users—United States, 2002-2013.
      • Jones C.M.
      • Logan J.
      • Gladden R.M.
      • et al.
      Vital signs: demographic and substance use trends among heroin users—United States, 2002–2013.
      Drug overdose deaths nearly quadrupled in the 15- to 24-year-old age group from 1999 to 2016.
      • Hedegaard H.
      • Miniño A.M.
      • Warner M.
      Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329.
      What is already known on this topic
      A nonfatal opioid overdose is an opportunity to initiate medications to assist recovery from opioid use disorder.
      What question this study addressed
      What are the characteristics of patients aged 18 to 45 years with a nonfatal opioid overdose who receive treatment to help cure their disorder?
      What this study adds to our knowledge
      Using a 2012 to 2014 Massachusetts database with 4,268 treated patients, depending on age strata, medication-assisted therapy was started in 28% to 36% and varied by agent used and initiation timing.
      How this is relevant to clinical practice
      This study demonstrates one path to more consistent deployment of treatment for younger adult opioid use disorder patients.
      Young adults have distinct developmental differences that predispose them to substance use disorders. During this developmental period, the reward system and resulting positive reinforcement are relatively more advanced than are inhibitory systems, leading to increased vulnerability to risky substance use and addiction.
      • Sussman S.
      • Arnett J.J.
      Emerging adulthood: developmental period facilitative of the addictions.
      Clinically, young adults respond to interventions differently than older adults,
      • Satre D.D.
      • Mertens J.
      • Areán P.A.
      • et al.
      Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program.
      • McCambridge J.
      • Strang J.
      The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial.
      emphasizing the need to better design appropriate interventions to engage and retain them in treatment. As deaths continue to increase among this age group, opportunities to identify and engage them are important to recognize.
      One such opportunity is presentation to the emergency department (ED) for nonfatal opioid overdose. Visits to EDs for suspected opioid overdoses increased 30% from July 2016 to September 2017.
      • Vivolo-Kantor A.M.
      • Seth P.
      • Gladden R.M.
      • et al.
      Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.
      • Houry D.E.
      • Haegerich T.M.
      • Vivolo-Kantor A.
      Opportunities for prevention and intervention of opioid overdose in the emergency department.
      Nonfatal opioid overdose is a significant predictor for recurrent nonfatal opioid overdose and for fatal overdose. Medications for opioid use disorder have been shown to not only improve abstinence and retention in care but also have a positive mortality benefit. Provision of medication for opioid use disorder in the period after an overdose may therefore be a critical strategy to address overdose deaths.

       Importance

      Given the increasing rate of opioid overdose deaths, the opportunity that surviving an opioid overdose provides, and the challenges of engaging young adults in care, it is important to characterize nonfatal opioid overdose incidence and subsequent treatment engagement, or lack thereof, in this age group. These data can provide a baseline to compare the effectiveness of efforts to improve medication for opioid use disorder initiation in the ED. Policymakers can begin to formulate interventions to respond to nonfatal overdose as a sentinel event in a high-risk, hard-to-engage population that could benefit from targeted prevention and treatment. Given the recent data showing success of initiating medication for opioid use disorder in the ED,
      • D’Onofrio G.
      • Chawarski M.C.
      • O’Connor P.G.
      • et al.
      Emergency department–initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention.
      a better understanding of treatment patterns after a nonfatal overdose could be an important way to tailor such interventions.

       Goals of This Investigation

      The aims of this study are to describe characteristics of young adults (18 to 25 years) who experience nonfatal overdose and estimate the time to medication for opioid use disorder treatment and rates of medication for it for individuals aged 26 to 45 years in the 12 months after nonfatal overdose.

      Materials and Methods

       Study Design

      We conducted a retrospective cohort study of individuals in Massachusetts, aged 18 to 45 years, who had a nonfatal overdose between January 1, 2012, and December 31, 2014.

       Data Collection and Processing

      Chapter 55 of the Acts of 2015 mandated that the Massachusetts Department of Public Health analyze data from several Massachusetts government agencies and allowed the linkage of these data sets to identify and report on trends among persons who experienced fatal and nonfatal opioid overdose.
      The General Court of the Commonwealth of Massachusetts. Chapter 55: an act requiring certain reports for opiate overdoses.
      The Chapter 55 database includes Massachusetts residents aged 11 years and older who have public or private insurance.
      Data from disparate agencies were linked through a 10-level match protocol and subsequently deidentified at the Massachusetts Department of Public Health, allowing this study to examine the full course of patients during the study period, from 2011 to 2015. The 10 levels of matches were tested between the data sets in Chapter 55 data sets and identifiers in the All Payers Claim Database. Data linkage was conducted by the Center for Health Information and Analysis in consultation with the Massachusetts Department of Public Health. All matches were deterministic. To improve accuracy, no close matches were used. The matching procedure produced matching from 71% to 100%. To obtain access to the data, our team submitted a proposal to the Massachusetts Department of Public Health for approval; all analyses occurred on site at the department.
      To construct the set of variables needed for this study, we used data from the All Payers Claim Database, Massachusetts Department of Public Health Bureau of Substance Addiction Services, the Massachusetts Prescription Monitoring Program, Massachusetts Ambulance Trip Record Information System, and Massachusetts Acute Hospital Case Mix.
      • Baker C.D.
      • Polito K.E.
      • Sudders M.
      • et al.
      An Assessment of Fatal and Nonfatal Opioid Overdoses in Massachusetts (2011-2015).

       Selection of Participants

      Individuals entered the cohort when they experienced a nonfatal overdose between January 1, 2012, and December 31, 2014, in Massachusetts, providing a full 12 months of observation before and after the nonfatal overdose. Each individual contributed only his or her first nonfatal overdose event in the data set window. Recurrent nonfatal overdose events were excluded. Nonfatal overdose was identified in 2 ways. First, any individual who had an ambulance encounter related to opioid overdose was included. The algorithm used to identify opioid-related overdoses in the emergency medical services data resulted from a collaboration between the Massachusetts Department of Public Health and the Centers for Disease Control and Prevention.
      • Green C.A.
      • Perrin N.A.
      • Janoff S.L.
      • et al.
      Assessing the accuracy of opioid overdose and poisoning codes in diagnostic information from electronic health records, claims data, and death records.
      The second was an ED, observation, or hospital encounter with an International Classification of Diseases, Ninth Revision (ICD-9) code containing a diagnosis code for opioid poisoning (965.00 to 965.02, 965.09, and E85.00 to E85.02).
      • MacArthur G.J.
      • Minozzi S.
      • Martin N.
      • et al.
      Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis.
      Visits to Veterans Administration hospitals were not included. There were 558 events that were removed from the analysis because death occurred within 30 days of the overdose.
      The primary independent variable was age group, categorized as aged 18 to 21, 22 to 25, and 26 to 45 years. Young adulthood is a transitional period in which changes in brain function, social capital, and individual responsibility are greater than in other periods. Therefore, we subcategorized the age group to understand whether the characteristics and medication experience were consistent throughout the period. This has been shown in previous work that has revealed differences between aged 18 to 21 and 22 to 25 years. We chose to use the age group of 26 to 45 years as the comparison group because at aged 26 years, brain myelination of the frontal lobe has matured. This is also the age when young adults are no longer eligible to be on their parents’ health insurance. We capped the age group at 45 years so that our observations were not affected by the increasing onset of the chronic illnesses of aging, such as chronic obstructive pulmonary disease, chronic liver disease from hepatitis C infection, and alcohol and cardiovascular disease.
      We included in the multivariable models the following covariates: sex (from the All Payers Claim Database), anxiety, and depression. Anxiety and depression were identified through ICD-9 and -10 diagnosis codes (anxiety 300.X and F41.X; depression 296.2X, 296.3X, 296.99, 300.4, 311, 625.4, F32.X, F33.X, F34.1, and F34.8X) and defined as having a claim for these conditions any time between 2011 and 2015. Homelessness was identified with ICD-9 diagnosis code V60.0 or ICD-10 diagnosis code Z590 in the All Payers Claim Database. Receipt of opioid prescriptions in the past 12 months was obtained from the Prescription Monitoring Program. We included involuntary commitment to substance use treatment through a special statute specific to Massachusetts because of risk to self or others in the previous 12 months before the nonfatal overdose, from the Bureau of Substance Addiction Services. The other covariates were Bureau of Substance Addiction Services–funded inpatient medical detoxification and residential substance use treatment (defined as any treatment beyond medical detoxification) in the 12 months before nonfatal overdose.

       Outcome Measures

      The primary outcome was receipt of medication for opioid use disorder, defined as follows: buprenorphine obtained from the Prescription Monitoring Program; oral or injectable naltrexone, obtained from the All Payers Claim Database; or methadone treatment as identified in Bureau of Substance Addiction Services or All Payers Claim Database data (identified by Healthcare Common Procedure Coding System code H0020). Receipt of medication for opioid use disorder was identified in each month, starting with the month of the nonfatal overdose through 12 months afterward.

       Primary Data Analysis

      We used summary statistics to describe characteristics of the cohort. We examined time to receipt of medication for opioid use disorder after nonfatal overdose by estimating Kaplan-Meier survival curves stratified by age groups (ie, 18 to 21, 22 to 25, and 26 to 45 years). Individuals were censored at 12 months or at death. We chose 12 months so we would have the same amount of follow-up time for all individuals in the cohort. We calculated median time to treatment in months and median duration of medication in months. We developed multivariable Cox proportional hazards models to compare rates of treatment receipt after nonfatal overdose, adjusting for sex, anxiety or depression diagnosis, homelessness, past-year benzodiazepine prescription, past-year opioid use disorder medication treatment, past-year detoxification admission, past-year residential treatment, and past-year involuntary commitment. We used SAS Studio for the analysis (version 3.5; SAS Institute, Inc., Cary, NC).
      We received a Not Human Subjects Research determination from the Boston University Medical Campus Institutional Review Committee.

      Results

       Characteristics of Study Subjects

      Of 15,281 individuals aged 18 to 45 years and with a nonfatal overdose who encountered medical care, 4,268 (28%) were young adults (ie, 18 to 25 years). Greater proportions of young adults were women and had been involuntarily committed in the year before the nonfatal overdose. Among patients aged 18 to 21 years, 10% received buprenorphine (n=118/1,209), 7% received naltrexone (n=87/1,209), and 4% received methadone (44/1,209) in the year preceding nonfatal overdose. Among patients aged 22 to 25 years, 13% received buprenorphine (410/3,059), 8% received naltrexone (232/3,059), and 9% received methadone (n=260/3,059) in the year preceding nonfatal overdose. In the year after the nonfatal overdose, we observed the following mortality: 3% (n=31) of individuals aged 18 to 21 years, 2% (n=64) of individuals aged 22 to 25 years, and 4% (n=398) of individuals aged 26 to 45 years. Other characteristics are shown in Table 1.
      Table 1Characteristics of individuals aged 18 to 45 years who survived a nonfatal opioid-related overdose in Massachusetts between 2012 and 2014, stratified by age group (N=15,281).
      Variables18–21 Years, N=1,20922–25 Years, N=3,05926–45 Years, N=11,013
      %95% CI%95% CI%95% CI
      Women43.841–46.63836.68–40.1233.532.62–34.38
      Homeless history10.78.96–12.4413.712.48–14.9218.317.58–19.02
      Incarceration history4.02.9–5.16.75.81–7.596.35.85–6.75
      Involuntary commitment
      Massachusetts allows involuntary commitment through the court system to mandate treatment for individuals whose alcohol or substance use presents an acute risk to their health.
      7.56.02–9.988.27.23–9.174.23.83–4.57
      Anxiety diagnosis, ever15.913.84–17.9615.614.31–16.8920.319.55–21.05
      Depression diagnosis, ever17.715.55–19.8517.516.15–18.8523.322.51–24.09
      Past-year opioid prescription
      This does not include buprenorphine.
      31.228.59–33.8140.138.36–41.8439.638.69–40.51
      Past-year benzodiazepine prescription11.29.42–12.9817.416.06–18.7427.526.67–28.33
      Past-year buprenorphine9.88.12–11.4813.412.19–14.6114.313.65–14.95
      Past-year naltrexone7.25.74–8.667.66.66–8.544.94.5–5.3
      Past-year methadone3.62.55–4.658.57.51–9.4913.012.37–13.63
      State-funded detoxification program before nonfatal overdose in past year21.919.57–24.2330.929.26–32.5428.827.95–29.65
      State-funded residential program before nonfatal overdose in past year97.39–10.6111.410.27–12.5311.310.71–11.89
      Massachusetts allows involuntary commitment through the court system to mandate treatment for individuals whose alcohol or substance use presents an acute risk to their health.
      This does not include buprenorphine.
      In the 12 months after a nonfatal overdose, 35% of individuals aged 18 to 45 years received any medication treatment. Of individuals aged 18 to 21 years who had a nonfatal overdose, 28% received any medication treatment (7% methadone, 16% buprenorphine, and 10% naltrexone). Of individuals aged 22 to 25 years, 36% received any medication treatment (12% methadone, 20% buprenorphine, and 10% naltrexone) (Figure 1). The median time to treatment is reported in Table 2. The median time treated with buprenorphine was 2 months (interquartile range [IQR] 1 to 6 months), 2 months (IQR 1 to 6 months), and 3 months (IQR 1 to 7 months) for individuals aged 18 to 21, 22 to 25, and 26 to 45 years, respectively. The median time treated with methadone was 4 months (IQR 2 to 8 months), 4 months (IQR 2 to 9 months), and 5 months (IQR 2 to 9 months) for individuals aged 18 to 21, 22 to 25, and 26 to 45 years, respectively. The median time treated with naltrexone was 1 month (IQR 1 to 1 month) for all age groups.
      Figure thumbnail gr1
      Figure 1Receipt of medication treatment in the 12 months after a nonfatal overdose, stratified by age groups. Error bars represent 95% CI.*. *Individuals could have received more than one kind of medication type.
      Table 2Median time to
      Median time in months to receipt of medication treatment
      medication treatment in the months after a nonfatal overdose, by age groups (IQR).
      Age Group, YearsTime to Treatment
      BuprenorphineMethadoneNaltrexone
      18–214 (1–8)5 (1–8)4 (2–8)
      22–254 (1–7)3 (1–8)4 (1–8)
      26–453 (1–7)3 (1–6)4 (2–8)
      Median time in months to receipt of medication treatment
      The unadjusted survival analysis shows that a smaller proportion of patients aged 18 to 21 years received methadone, buprenorphine, or any medication for opioid use disorder overall (Figure 2A, B, and D). A higher proportion received naltrexone (Figure 2C). However, in the multivariable adjusted Cox regression model, no differences in receipt of any medication for opioid use disorder were detected by age group (adjusted hazard ratios 0.91 [95% confidence interval {CI} 0.81 to 1.02] and 1.06 [95% CI 0.99 to 1.13] for individuals aged 18 to 21 and 22 to 25 years, respectively, compared with those aged 26 to 45 years). However, individuals aged 18 to 21 years were less likely (adjusted hazard ratio 0.60 [95% CI 0.45 to 0.70]) to receive methadone than those aged 22 to 25 and 26 to 45 years. Individuals aged 18 to 21 and 22 to 25 years were more likely to receive naltrexone (adjusted hazard ratio 1.65 [95% CI 1.36 to 2.00] and 1.41 [95% CI 1.23 to 1.61]) than those aged 26 to 45 years. There was no difference among receipt of buprenorphine. There was a higher probability of naltrexone receipt in individuals with past-year involuntary commitment, past-year detoxification, and past-year residential treatment (Table 3).
      Figure thumbnail gr2ab
      Figure 2A, Proportion of individuals aged 18 to 45 years who received methadone in the 12 months after nonfatal overdose, by age groups. B, Proportion of individuals aged 18 to 45 years who received buprenorphine in the 12 months after nonfatal overdose, by age groups. C, Proportion of individuals aged 18 to 45 years who received naltrexone in the 12 months after nonfatal overdose, by age groups. D, Proportion of individuals aged 18 to 45 years who received any medication treatment in the 12 months after nonfatal overdose, by age groups.
      Figure thumbnail gr2cd
      Figure 2A, Proportion of individuals aged 18 to 45 years who received methadone in the 12 months after nonfatal overdose, by age groups. B, Proportion of individuals aged 18 to 45 years who received buprenorphine in the 12 months after nonfatal overdose, by age groups. C, Proportion of individuals aged 18 to 45 years who received naltrexone in the 12 months after nonfatal overdose, by age groups. D, Proportion of individuals aged 18 to 45 years who received any medication treatment in the 12 months after nonfatal overdose, by age groups.
      Table 3Adjusted hazard ratio and 95% CI of multivariable Cox proportional hazards models for time to treatment after nonfatal overdose.
      CharacteristicBuprenorphineMethadoneNaltrexoneAny Medication Treatment
      26–45 y1 [Reference]1 [Reference]1 [Reference]1 [Reference]
      18–21 y0.99 (0.85–1.14)0.60 (0.45–0.70)
      Significant results.
      1.65 (1.36–2.00)
      Significant results.
      0.91 (0.81–1.02)
      22–25 y1.10 (0.99–1.19)0.91 (0.81–1.02)1.41 (1.23–1.61)
      Significant results.
      1.06 (0.99–1.13)
      Women0.86 (0.80–0.93)
      Significant results.
      1.45 (1.32–1.58)
      Significant results.
      0.94 (0.83–1.06)1.01 (0.95–1.07)
      Homeless history1.08 (0.98–1.18)1.36 (1.23–1.51)
      Significant results.
      1.06 (0.92–1.23)1.14 (1.07–1.26)
      Significant results.
      Involuntary commitment1.08 (0.94–1.25)0.89 (0.75–1.07)
      Significant results.
      1.48 (1.22–1.80)
      Significant results.
      1.02 (0.92–1.13)
      Past-year anxiety1.08 (0.98–1.20)0.95 (0.84–1.08)1.24 (1.05–1.46)
      Significant results.
      1.06 (0.98–1.15)
      Past-year depression0.99 (0.90–1.10)0.96 (0.85–1.08)1.23 (1.05–1.44)
      Significant results.
      1.07 (0.99–1.15)
      Past-year prescription for benzodiazepines1.28 (1.18–1.40)
      Significant results.
      0.99 (0.89–1.10)0.90 (0.78–1.04)1.10 (1.03–1.17)
      Significant results.
      Past-year medication treatment for opioid use disorder3.04 (2.79–3.32)
      Significant results.
      3.71 (3.36–4.10)
      Significant results.
      1.09 (0.92–1.27)4.16 (3.89–4.45)
      Significant results.
      Past-year state-funded admission for detoxification1.08 (0.99–1.17)1.50 (1.36–1.65)
      Significant results.
      1.62 (1.43–1.85)
      Significant results.
      1.30 (1.26–1.38)
      Significant results.
      Past-year state-funded residential treatment1.18 (1.06–1.32)
      Significant results.
      1.06 (0.93–1.21)1.40 (1.19–1.64)
      Significant results.
      1.13 (1.04–1.23)
      Significant results.
      Significant results.

      Limitations

      This study used data from Chapter 55 of the Acts of 2015 of individuals who experienced a nonfatal opioid-related overdose. This data set could not identify individuals who survived an overdose but did not have an ambulance or hospital encounter. But we were able to include all overdose-related acute hospital discharges and ambulance encounters across all providers in Massachusetts. It is possible that not every individual had a known diagnosis of opioid use disorder before the nonfatal overdose. However, opioid overdose is almost always a qualifying criterion for opioid use disorder, and thus receipt of medication for opioid use disorder. It is not possible to confirm adherence completely to medication according to administrative data, but high concordance between self-report, electronic pharmacy records, and medication lids has been demonstrated in other studies.
      • Hansen R.A.
      • Kim M.M.
      • Song L.
      • et al.
      Adherence: comparison of methods to assess medication adherence and classify nonadherence.
      Also, data are not clustered by hospital center or provider. It is likely that there are some locations across the state that provide coordination of care and linkage of treatment that others do not. As noted in the “Materials and Methods” section, we excluded individuals who had a death within 30 days of the overdose. Table E1 (available online at http://www.annemergmed.com) provides age and other demographic data on these individuals. Exclusion of these individuals introduces survivor bias.
      The database did not include good indicators for race, HIV, hepatitis C virus, and socioeconomic status. These factors have been previously associated with opioid-related treatment and overdose and should be better characterized in future studies. We did not include insurance status because insurance coverage was between 96% and 97% during the study period.
      • Henry J.
      Kaiser Family Foundation
      Health insurance coverage of the total population.
      Our data and our analyses are limited to 2011 to 2015, which included the period in Massachusetts when fentanyl emerged as a major driver of overdose deaths. Massachusetts was one of the first states affected by fentanyl, and thus, the 2011 to 2015 timeframe reflects what has happened nationally more recently.
      • Rudd R.A.
      Increases in drug and opioid-involved overdose deaths—United States, 2010-2015.
      Furthermore, Massachusetts was an early adopter of near-universal health care coverage, increased access to medication treatment, and naloxone for overdose prevention, which means that the care environment in Massachusetts represents what other states have been adopting.
      Massachusetts Department of Public Health
      Data brief: opioid-related overdose deaths among Massachusetts residents (2018-11).
      Center for Health Information and Analysis
      Access to substance use disorder treatment in Massachusetts.
      An additional limitation is that we calculated the time in treatment only within the 12-month window of the study. Although the median times were all less than 12 months, it would be interesting to look in future studies beyond 12 months of treatment to identify potential differences by age. Finally, because the data are from Massachusetts residents, the results may not be fully reflective of other populations.

      Discussion

      In this study of individuals aged 18 to 45 years who survived opioid overdose in Massachusetts between 2012 and 2014, approximately 1 in 3 young adults received evidence-based, recommended medication treatment with buprenorphine, naltrexone, or methadone in the subsequent 12 months. The median time to all types of medication treatment was between 3 and 5 months for all age groups, with time in treatment highest for those receiving methadone and buprenorphine. Young adults were more likely to receive naltrexone than older ones, and younger young adults (18 to 21 years) were less likely to receive methadone.
      These data highlight a missed opportunity to engage all adults, including young adults in treatment after nonfatal overdose. The median time to treatment found in this study was at least 4 months, which underscores substantial room for improvement in the timing required to engage them in care. For young adults, providing timely treatment after a near-fatal event offers a chance for earlier intervention and prevention of the long-term physical and social consequences of ongoing substance use. The stakes are high because the mortality is high: 2% or more of individuals in each age group who survive an opioid overdose die within 12 months.
      • Larochelle M.R.
      • Bernson D.
      • Land T.
      • et al.
      Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.
      Despite the increased efforts to initiate buprenorphine in the ED since the study by D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      was published, there is no evidence or clinical guidance for administering buprenorphine in the midst of naloxone-precipitated withdrawal. In that study, only 8% of the participants had presented with an overdose. More work is needed to demonstrate the feasibility and safety of medication for opioid use disorder immediately after an overdose.
      In addition, we found variation in type of medication received by age group, and the consequences of that variation may have important implications. Young adults aged 18 to 21 years were less likely than the older young adults (ie, 22 to 25 years) to receive methadone after a nonfatal overdose, even though the evidence for methadone treatment is the best established among all 3 Food and Drug Administration–approved medications. Methadone has been shown to improve retention, decrease risk for HIV, and, most important, decrease risk for death.
      • Sordo L.
      • Barrio G.
      • Bravo M.J.
      • et al.
      Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.
      • Matson S.C.
      • Hobson G.
      • Abdel-Rasoul M.
      • et al.
      A retrospective study of retention of opioid-dependent adolescents and young adults in an outpatient buprenorphine/naloxone clinic.
      There are potential barriers to treating young adults with methadone; it is associated with significant stigma, and also federal rules that severely limit access to methadone to individuals younger than 18 years may make methadone a less recognized option for young adults. However, in this study, similar to other studies, methadone had the best retention in treatment for all age groups.
      • Olsen Y.
      • Sharfstein J.M.
      Confronting the stigma of opioid use disorder—and its treatment.
      There was no significant difference in receipt of buprenorphine among young adults. Nonetheless, the overall proportion of people receiving buprenorphine was still less than 20%. Expansion of medication for opioid use disorder is a critical component of federal and state responses to the increasing opioid-related overdose rate in the United States, and this study demonstrates that for all age groups, there continues to be a wide treatment gap that must be bridged.
      We also found that young adults had a higher probability of receiving naltrexone in the 12 months after nonfatal overdose than older adults. However, the median time receiving it was only 1 month. The effectiveness of a medication is limited to the time people receive it; therefore, improving medication retention is a crucial challenge for individuals prescribed naltrexone. Naltrexone is the least studied of the 3 medications indicated for opioid use disorder. Further studies should examine how young adult patients and their providers make decisions in regard to which medication for opioid use disorder to use, including what structural factors (eg, state regulations, insurance coverage) contribute to medication for opioid use disorder selection. These findings further underscore the need for a more nuanced understanding of how medication choices are being made by patients and providers.
      In summary, this study documents low proportions of young adults who receive medication for opioid use disorder after a nonfatal overdose and further advances the evidence base of the types of, time to, and duration of medication treatment received by young adults compared with older adult groups. Knowing that young adults respond to interventions and treatment differently than older adults
      • Satre D.D.
      • Mertens J.
      • Areán P.A.
      • et al.
      Contrasting outcomes of older versus middle-aged and younger adult chemical dependency patients in a managed care program.
      is an important step in improving care for this population. The differences in rate of treatment receipt, types of medication treatment, and duration of medication treatment between individuals aged 18 to 21 and 22 to 25 years suggest that even within the young adult population, tailored interventions for each age group may be required to best engage them.
      Future studies should seek to understand how young adults and providers choose medication for opioid use disorder and demonstrate the safety and feasibility of medication for opioid use disorder initiation postoverdose in the ED. Because the United States continues to experience increasing opioid-related deaths, strategies to ensure that all medications are available to all people regardless of age are needed, and the ED can be a critical link in identification and engagement for this highest-risk population.

      Supplementary Data

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      Linked Article

      • Postoverdose Initiation of Buprenorphine After Naloxone-Precipitated Withdrawal Is Encouraged as a Standard Practice in the California Bridge Network of Hospitals
        Annals of Emergency MedicineVol. 75Issue 4
        • Preview
          Recently, one of my patients described surviving a heroin overdose. After being found unconscious by paramedics and administered naloxone, he was transported to an emergency department (ED), where he was observed for several hours and discharged home. On the way home from the ED, he described feeling terrible; then, remembering he had some heroin tucked away in his sock, he proceeded to use it in the backseat of the car and overdosed again. From the perspective of the medical model of opioid addiction, this type of behavior is neither shocking nor surprising.
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      • In reply:
        Annals of Emergency MedicineVol. 75Issue 4
        • Preview
          We thank Dr. Herring for his response to our analysis comparing receipt of medication for opioid use disorder among young adults to that of older adults who experienced a nonfatal opioid overdose in Massachusetts.1 As deaths related to opioids continue to increase, we agree with him that there is a critical need to identify and initiate medication for opioid use disorder with postoverdose survivors. Postoverdose survivors are at the highest risk for subsequent fatal overdose, and medication for opioid use disorder consistently shows a protective effect against mortality.
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