Opioid overdose has been a persistent public health crisis for decades, with the emergency department becoming a critical touchpoint for overdose survivors. However, most patients treated in an emergency department for an overdose never continue medications for opioid use disorder (MOUDs) after they go home even though MOUDs can reduce the mortality by at least 50%.
A new clinical trial at UAB is testing whether a proactive, bundled intervention delivered largely by phone and video can close this critical gap. The intervention is led by Li Li, M.D., Ph.D., professor in the Department of Psychiatry and Behavioral Neurobiology. The clinical trial, funded through a two-phase R61/R33 mechanism by NIDA, first tests whether the bundled intervention is feasible and acceptable to patients, and then tests its effectiveness by comparing it against usual care in a randomized trial.
The problem with the weeks after hospital discharge
Studies report that fewer than 5.2% of Medicaid patients and about 11.7% of commercially insured patients treated for a nonfatal opioid overdose continue MOUDs after discharge, and only 37% of emergency department referrals lead to treatment engagement at 30 days. UAB has seen similar patterns.
“We can start the right medication in the emergency department and provide treatment resources to patients, but a prescription and a list of programs are not enough for someone leaving the hospital after an overdose,” Li said. “The first three months are when people are most likely to overdose again, and that is exactly when our system tends to lose them.”
A bundled approach
The bundled intervention includes four key, evidence-based components. Peer support specialists, who combine their own lived experience of substance use and recovery with formal training, improve engagement and retention in treatment. Low-threshold buprenorphine increases access to medication. Telehealth for addiction care is associated with higher patient satisfaction, better retention, and lower costs. Connection to a community treatment program is associated with a threefold increase in abstinence and a fivefold reduction in overdose deaths.
In the trial, participants with recent non-fatal opioid overdose will start on buprenorphine and meet a certified peer support specialist before they leave the hospital. Over the next 12 weeks, the peer stays in contact by phone or video daily in the first week, and then tapering to weekly to support recovery, help navigate treatment resources, remind participants to take their medication, and connect them with a community program for long-term care. Addiction physicians see participants by telehealth every two weeks and then monthly to continue buprenorphine. The study provides participants with a free mobile phone and paid buprenorphine as needed.
As of now, the study team has completed the first phase, R61, by enrolling 30 participants to measure enrollment, retention, participant satisfaction, and participant confidence in the treatment. The second phase will randomize 160 participants to the bundled intervention or to usual care, which includes buprenorphine initiation, a peer referral, and a written list of clinics and addiction programs. The team will compare retention in treatment, buprenorphine adherence, linkage to a community program, repeat overdoses, and return visits to the emergency department. They will track overdoses and emergency visits in the medical record throughout the four-year study.
The hope ahead
This trial brings together UAB’s emergency department, addiction physicians, certified peer support specialists, UAB eMedicine’s telehealth platform, and community partners. UAB’s collaborative research environment and the study team have made the study possible, bringing together the clinicians, peers, and patients needed to test this new approach to care for overdose survivors.
“An overdose visit is a reachable moment,” Li said. “Patients are often ready to engage. What we are testing is whether this novel intervention can turn that moment into lasting treatment.”