Can peer recovery coaches in the emergency room help link people with opioid use disorder to treatment?

Every day thousands of people in the United States are brought to hospital emergency departments for medical treatment of an opioid overdose, yet rarely are these individuals provided with meaningful addiction treatment beyond stabilization. This study described outcomes of an innovative emergency department program that linked individuals who experienced an opioid overdose with a peer recovery coach—addiction professionals who are in recovery themselves.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Every day thousands of people in the United States are brought to hospital emergency departments for opioid overdose treatment. These kinds of hospital visits provide an excellent opportunity for providers to offer psychosocial care for individuals with opioid use disorder, and direct them to addiction treatment. This study asks if peer recovery coaches (individuals themselves in substance use disorder recovery) can be used in the emergency room environment to assess patients’ readiness to seek treatment, identify overdose risk factors, and provide individualized support to help people navigate the complexities of accessing addiction treatment. The authors investigated whether patients in their study initiated a medication for opioid use disorder (e.g., buprenorphine, methadone, and naltrexone), had subsequent emergency department visits for an opioid overdose, and patient fatalities one year after patients’ initial emergency department visit for accidental opioid overdose treatment.

HOW WAS THIS STUDY CONDUCTED?

This is an observational, retrospective outcome study of 151 emergency department patients treated and discharged after receiving either, 1) usual care, 2) take-home naloxone (a medication that reverses the effects of opioid overdose), or 3) peer recovery coach consultation + take-home naloxone. All adult patient records from the study hospitals during the study period were screened for opioid overdose. Patient records were included in the study if individuals were treated and discharged after an accidental, nonfatal opioid overdose. Only the first visit during the study period was included in the analyses. Medical records of included patients were reviewed one year from their initial emergency department visit to determine their outcomes.

READ MORE ON STUDY METHODS

Patients were categorized as having received one of the following interventions while in the emergency department. The kind of treatment patients received was determined by patient need, provider discretion, and availability of services:

Usual care, which consisted of medical stabilization and provision of a list of substance use treatment programs provided in printed discharge instructions.
Take-home naloxone kits included two doses of 2 mg intranasal naloxone, a mucosal atomizer device, and pictorial and verbal assembly and administration instructions in English and Spanish. Education for patients, family members, and friends about overdose prevention, response, and naloxone administration was conducted with an educational video, and a bilingual printed handout.
Peer recovery coaching + take-home naloxone kits. Peer recovery coaches were paid individuals with at least two years of addiction recovery who had completed a 36-hour peer recovery coach training covering motivational interviewing, opioid agonist treatment, and provision of peer-to-peer support. Using motivational interviewing techniques and a stages of change behavioral framework, coaches assessed patients’ readiness to seek treatment, identified overdose risk factors, and provided individualized support and addiction treatment navigation, including linkage to medication for opioid use disorder (i.e., buprenorphine, methadone, and naltrexone), at the time of and for at least 90 days after the emergency department visit. Recovery coaches had a patient contact protocol instructing them to follow-up with patients within 48 hours of their emergency department visit, then at least weekly for at least 90 days.

Primary outcomes included whether patients initiated a medication for opioid use disorder (e.g., buprenorphine, methadone, and naltrexone), repeat emergency department visits for an opioid overdose, and all-cause death one year after patients’ initial emergency department visit for opioid overdose treatment.

WHAT DID THIS STUDY FIND?

Initiation of a medication for opioid use disorder

No patients were started on medication for opioid use disorder in the emergency department, and less than a third of patients included in the study (28.5%, 48/151) initiated medication for opioid use disorder within the year after their emergency department visit. Proportions of patients initiating medication for opioid use disorder were similar between the usual care and take-home naloxone groups, but in absolute terms there was a shorter time to initiation of medication for opioid use disorder among those who got a recovery coach and naloxone compared to usual care (81 days vs. 107 days).

Repeat emergency department visits for opioid overdose

Thirty patients (19.9%) were treated for a repeat opioid overdose at a study site emergency department within one year from their initial emergency department visit, however, a smaller proportion of those receiving a recovery coach had a repeat overdose compared to the usual care group. In absolute terms, those in the naloxone group had the lowest incidence of repeat emergency department visit for opioid overdose and a statistical trend toward longer median time to repeat emergency department visit for opioid overdose.

All-cause death

Of those in the study sample, 7 (4.6%) participants died within a year of their emergency department visit, with half of these deaths occurring within 123 days. In absolute terms, a smaller proportion of deaths occurred among those receiving take home naloxone or a recovery coaching with naloxone and had a longer median time to death.

Primary overall outcomes: 29% received meds, 20% had a repeat visit to ED (at one of the two sites), and 5% died.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

It is noteworthy that no patient included in the study was started on medication for opioid use disorder while in the emergency department. While this is typical, this represents a critical missed opportunity to reduce future overdose risk, and help individuals recover from opioid use disorder, especially because starting individuals on medications for opioid use disorder can increase treatment engagement and reduce opioid use. Additionally, it is known that providing brief substance use disorder interventions in emergency departments can reduce long-term costs to healthcare systems. Though groups were not statistically significantly different in length of time to initiation of opioid use disorder medication, those receiving recovery coaching had a notably shorter time to medication initiation compared to those receiving usual care, suggesting in a limited way the potential of recovery coaches in the emergency department environment. Repeat emergency department visits for opioid overdose, however, were not markedly different between groups, nor were all-cause deaths. Though the present findings may at face value diminish enthusiasm for peer recovery coaching in the emergency department environment, the present findings should be viewed in light of the fact opioid use disorder typically requires an intensive level of sustained care. It is perhaps unreasonable to think that peer recovery coaches alone may be able to significantly impact all-cause death. Nevertheless, it is quite possible that peer recovery coaches may be able to help medication initiation, and most importantly, this study demonstrates the feasibility of utilizing peer recovery coaches in the emergency department environment.

LIMITATIONS

As noted by the authors:

This study utilized a research design that didn’t allow for determination of whether the recovery coaching and naloxone intervention was effective. For instance, emergency department doctors may have requested recovery coaches for individuals with greater opioid use disorder severity, and if these patients did not respond to the intervention it may have been because they had more challenges, not because the intervention was ineffective. It should be noted that randomization in this context would not be ethical, and as such, the authors were limited by the types of research designs they could utilize.
The authors note that recovery coach contact with patients was variable and not controlled for in the statistical analyses, meaning this factor could have influenced study outcomes in unknown ways.
The actual incidence of recurrent opioid overdose is also underestimated, as the authors were not able to count emergency department visits at other hospitals and incidence of overdoses not transported to the emergency department.

BOTTOM LINE

For individuals & families seeking recovery: The present study was not designed in such a way that it could properly test the effectiveness of peer recovery coaches in the emergency departments. Nevertheless, peer recovery coaches have been shown in other studies to be of great value to individuals with opioid use disorder, and addictions to other drugs including alcohol. There is also little to no down-side of working with peer recovery coaches.
For scientists: Recovery coaches are increasingly being utilized in hospital settings, and in theory have great potential to ameliorate the problem of opioid use disorder. More research is needed, however, to determine the effectiveness of peer recovery coaches, and under what conditions they can be most effective.
For policy makers: Peer recovery coaches have been shown to aid addiction recovery in a number of clinical contexts. Recovery coaches, however, are always limited by the systems they work in, which often do not actively support addiction recovery. Increasing individuals access to form of addiction care known to aid recovery (such as medications like methadone and Suboxone) is a critical next step. Improving access to clinical care will improve the ability of peer recovery coaches to support individuals with opioid use disorder, as well as other addictions.
For treatment professionals and treatment systems: The evidence presented in this article should not necessarily be construed as a failure of peer recovery coaches. A growing literature suggests they can be effective add-ons to treatment as usual in a variety of treatment contexts. Recovery coaches may produce better outcomes if patients’ barriers to care are reduced. For instance, if emergency department initiated agonist medication treatment for people presenting with accidental overdose, recovery coaches may have more success helping patients adhere to their prescription, than helping them initiate medication in the community.

CITATIONS

Samuels, E. A., Bernstein, S. L., Marshall, B. D. L., Krieger, M., Baird, J., & Mello, M. J. (2018). Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes. Journal of Substance Abuse Treatment, 94, 29-34. doi:10.1016/j.jsat.2018.07.013