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2023 HSR&D/QUERI National Conference Abstract

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1041 — Patient- and Setting-Related Gaps and Implementation Targets for VA Naloxone Distribution

Lead/Presenter: Elizabeth Oliva,  COIN - Palo Alto
All Authors: Oliva EM (VA Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System), Hong J (VA Health Economics Resource Center, VA Palo Alto Health Care System) Bounthavong M (VA Health Economics Resource Center, VA Palo Health Care System) Martins, SB (VA Center for Innovation to Implementation, VA Palo Alto Health Care System) Humphreys K (VA Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford University School of Medicine) Boothroyd D (Quantitative Sciences Unit, Stanford University School of Medicine) Bohnert ASB (VA Center for Clinical Management Research, Ann Arbor, MI) Garrido MM (VA Partnered Evidence-based Policy Resource Center, Boston VA Health Care System) Wu J (VA Center for Innovation to Implementation, VA Palo Alto Health Care System) Bustamante R (VA Center for Innovation to Implementation, VA Palo Alto Health Care System)

Objectives:
In response to the opioid overdose crisis and Comprehensive Addiction and Recovery Act of 2016 (CARA), VA has dramatically expanded access to the opioid overdose reversal medication naloxone. To enhance implementation of naloxone distribution, this study identifies gaps and implementation targets for patients with Opioid Use Disorder (OUD) and patients prescribed opioid analgesics (OpioidRx) who were candidates for naloxone distribution.

Methods:
Using data from VA’s Corporate Data Warehouse, we identified yearly cohorts of patients with OUD and/or OpioidRx from Fiscal Years 2014 to 2019 (FY2014-FY2019). We examined patient- and setting-related factors associated with naloxone distribution using generalized linear mixed models accounting for clustering of patients within facilities (e.g., demographics, diagnoses, health care settings, prescriptions, predictive model-based risk for adverse outcomes—specifically, VA’s Stratification Tool for Opioid Risk Mitigation [STORM] and Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression [RIOSORD]).

Results:
The number of patients with an indication for naloxone decreased between FY2014 to FY2019, dropping from 1,391,873 in FY2014 (2.2% OUD-only, 2.0% OUD+OpioidRx, 95.8% OpioidRx-only) to 828,178 in FY2019 (6.1% OUD-only, 2.4% OUD+OpioidRx, 90.3% OpioidRx-only). Rates of naloxone distribution increased from 0.1% in FY2014 (n = 658, 58.7% OUD-only) to 11.7% in FY2019 (n = 97,151, 63.8% OpioidRx-only). In FY2019, patients under 30 years or between 30 to 50 years had significantly lower odds of naloxone receipt than those who were 65 years and older (Odds Ratio [OR] = .76, 95% Confidence Interval [CI] = .71-.80; OR = .85, CI = .83-.87, respectively). Hispanic patients had significantly lower odds of naloxone receipt than non-Hispanic patients (OR = .80, CI = .77-.83) and Black patients had lower odds of naloxone receipt than White patients (OR = .94, CI = .92-.96). Conversely, American Indian patients had higher odds of naloxone receipt than White patients (OR = 1.12, CI = 1.05-1.21). Rural and highly rural patients had significantly higher odds of naloxone receipt than urban patients (OR = 1.11, CI = 1.09-1.13 and OR = 1.17, CI = 1.10-1.25, respectively). Patients seen in certain health care settings had significantly higher odds of receiving naloxone compared to those not seen in those settings (e.g., pain clinic, substance use disorder clinic, mental health treatment, Veterans Justice Program; significant ORs ranged from 1.08-2.38), whereas odds of receiving naloxone were significantly lower in emergency department/urgent care (OR = .74, CI = .73-.76) and surgery (OR = .57, CI = .56-.58). As VA and CARA intended, higher risk patients had significantly higher odds of receiving naloxone, with patients with OUD having higher odds than OpioidRx-only patients (e.g., OUD-only OR = 1.44, CI = 1.39-1.49) and higher predictive model-based risk patients—specifically, STORM and RIOSORD patients—having significantly higher odds compared to the lowest risk patients (STORM Very High-Risk OR = 5.75, CI = 5.46-6.05, RIOSORD Risk Class 10 OR = 22.27, CI = 20.52-24.17). Risk-based naloxone distribution was also observed among patients with higher morphine equivalent daily dose, long-acting opioids, benzodiazepines, and chronic obstructive pulmonary disease (significant ORs from 1.16-3.15).

Implications:
Despite increased naloxone distribution between FY2014 and FY2019, major gaps in naloxone distribution remain. In FY2019, only 12% of eligible patients with an indication received naloxone, including only 7% of surgical patients, 36% of patients with OUD, and 37% of Very High-Risk STORM patients.

Impacts:
This study identified important patient- and setting-related gaps in VA naloxone distribution that should become implementation targets.