Emergency Department-Based Medication for Opioid Use Disorder Program: Addressing Gaps in Linkages to Care

Background Emergency department (ED)-based medication for opioid use disorder (MOUD) has been shown to be effective in providing ease of access and successful treatment rates for patients with opioid use disorder (OUD). This study examined the social determinants of health (SDOH) of patients entering an ED-based MOUD program through individual and focus group surveys. SDOH may impact treatment retention for current and future patients. Methods A survey of all patients entering our MOUD program at two hospital-based EDs and two free-standing EDs was conducted from January to March 2022. Addiction care coordinators (ACCs) used standardized screening tools to enroll patients into the MOUD program, and trained research coordinators used a standardized form, using previously validated survey questions, to examine the role of SDOH. Focused group surveys were also collected. The survey measured patients’ perspectives of the program and solicited feedback on SDOH and program barriers. Results Of the 60 OUD patients inducted into the ED-based MOUD program during our survey period, 19 (32%) participated in an individual or focus group interview. Of these, 16 patients (27%) completed all survey questions. The mean age was 42 years old, 94% identified as Caucasian, and 65% were males. Over 94% of subjects found the ACCs helpful in providing follow-up care. Nearly 40% experienced transportation and financial issues. The vast majority found the MOUD program beneficial in coping with withdrawal symptoms, dealing with their addiction, and supporting recovery. Conclusion OUD patients found the ACCs and the MOUD program helpful for their transition to the treatment stage. The MOUD program can improve some patients’ reluctance to engage with a healthcare system by addressing barriers related to transportation to appointments and financial issues.


Introduction:
The United States has seen a significant increase in prescription drug misuse, leading to the opioid crisis.In .The annual OUD-related costs to the U.S. were $786.8 billion in 2018 [2].Despite the attention OUD has received, opioid deaths have significantly increased over the last 12 years [3].
Social determinants of health (SDOH) are critical elements related to OUD health outcomes.SDOH are nonclinical factors, including the conditions in which people are born, grow, live, work, and age [4][5].Addressing SDOH and improving health care are often interrelated and conflicting priorities [6][7].Difficulty procuring employment, transportation, or housing, for example, may pose immediate threats to well-being, making seeking healthcare a lower priority.

Measures
Metrics from the Health Opportunity and Equity (HOPE) Initiative [8] and State Health Improvement Plan (SHIP) [9] were used to develop questions for the standardized survey for the individual interviews and focus group survey.Focus group surveys concentrated on those SDOH that affected care and recovery in our MOUD program.The survey concentrated on mental health recovery questions, social and economic factors, as well as access to psychiatric care.Additionally, we inquired whether virtual services were helpful.
Using a standardized questionnaire process, patients were asked about their perspective on the program, SDOH barriers encountered, and constructive feedback to improve the program.Each patient was called and asked standardized questions about their experience.They were also invited to participate in a focus group interview and to offer non-scripted feedback.

Analysis
All responses were tabulated as counts and percentages.

Results
Results: Of the 60 OUD patients initiated on MOUD during the study period, 19 (31.7%) were entered, of which 16 (84%) completed all the survey questions.Participants ranged in age from 30 to 64, with a mean age of 42.All but one identified as white ethnicity (94%).Eleven of the 16 patients identified as male (69%) and five as female (31%).A zip code analysis noted a higher median income in the study population compared to the surrounding county.
Survey results regarding the ACC were largely positive.Participants reported the ACCs to be especially helpful in coordinating post-ED addiction care, organizing peer coach involvement, prompting engagement and treatment during ED visits, and addressing and overcoming financial and social barriers to MOUD (see Table 1).Over 90% felt comfortable with using telemedicine treatment for their OUD treatment.Survey respondents also felt the ACC helped them gain control of their lives (63% strongly agreed) and improved their overall health (57% agreed their health was better).
Respondents answered questions regarding barriers they experienced in obtaining care (see Table 2).Transportation, prescription, and financial issues were the most prevalent social barriers to remaining in treatment.

Discussion
Discussion: Understanding the diverse influences underlying the onset and maintenance of OUD is necessary for effective prevention and intervention strategies.SDOH are the root cause of health disparities [10][11].The SDOH framework aims to identify and address factors that impact health outcomes [12][13].Evidence suggests that optimizing SDOH as part of effective treatment may positively impact the lives and health outcomes of some with OUD.Furthermore, in a large longitudinal prospective cohort study of 615 heroin users, greater time spent in treatment for OUD was associated with improvements in aspects of SDOH, such as criminality, psychopathology, and mental health [14].
This study found that our ACCs successfully improved patient care in our ED-based MOUD program.As OUD is a significant health concern, emergency departments must develop programs to help people recover.Those most impacted by health disparities also tend to have less access to resources.10-11 The focus group survey concentrated on those SDOH that affected care, including mental health recovery questions and social and economic factors such as housing, education, transportation, employment, and access to psychiatric care.The study also ascertained whether virtual services were helpful.Providing virtual services could expand access and potentially reduce healthcare disparities if effective.

Conclusions
Conclusions: This study demonstrated the importance of collecting data on patient perspectives to inform programmatic strategy.From the individual interviews and focus groups the study ascertained information related to a significant strength of the program and the value of the ACC role.Opportunities to improve the program included scheduling appointments and transportation.Evaluating SDOHs will allow us to design program changes and interventions that address barriers, improve patient experience, and help patients stay in recovery.
estimated 2.7 million people in the United States had an opioid-use disorder (OUD)[1]