Overdose, Behavioral Health Services, and Medications for Opioid Use Disorder After a Nonfatal Overdose

Question  During the 12 months after a nonfatal drug overdose, what percentage of Medicare beneficiaries receive medications for opioid use disorder (MOUD), naloxone, or behavioral health services, what percentage have a subsequent nonfatal or fatal drug overdose, and how does receipt of these services affect fatal drug overdose risk?

Findings  In this cohort study of 136 762 Medicare beneficiaries with an index nonfatal drug overdose, subsequent nonfatal and fatal drug overdoses were observed. Subsequent nonfatal drug overdose and an opioid use disorder diagnostic code were associated with increased risk for fatal drug overdose, whereas receipt of a naloxone prescription, methadone, or buprenorphine treatment for opioid use disorder as well as behavioral health services were associated with decreased risk.

Meaning  Findings of this study suggest the need to improve access to behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care.

Importance  Recognizing and providing services to individuals at highest risk for drug overdose are paramount to addressing the drug overdose crisis.

Objective  To examine receipt of medications for opioid use disorder (MOUD), naloxone, and behavioral health services in the 12 months after an index nonfatal drug overdose and the association between receipt of these interventions and fatal drug overdose.

Design, Setting, and Participants  This cohort study was conducted in the US from January 2020 to December 2021 using claims, demographic, mortality, and other data from the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and other sources. The cohort comprised Medicare fee-for-service beneficiaries aged 18 years or older with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes for a nonfatal drug overdose. Data analysis was performed from February to November 2023.

Exposures  Demographic and clinical characteristics, substance use disorder, and psychiatric comorbidities.

Main Outcomes and Measures  Receipt of MOUD, naloxone, and behavioral health services as well as subsequent nonfatal and fatal drug overdoses.

Results  The cohort consisted of 136 762 Medicare beneficiaries (80 140 females [58.6%]; mean (SD) age of 68.2 [15.0] years) who experienced an index nonfatal drug overdose in 2020. The majority of individuals had Hispanic (5.8%), non-Hispanic Black (10.9%), and non-Hispanic White (78.8%) race and ethnicity and lived in metropolitan areas (78.9%). In the 12 months after their index nonfatal drug overdose, 23 815 beneficiaries (17.4%) experienced at least 1 subsequent nonfatal drug overdose and 1323 (1.0%) died of a fatal drug overdose. Opioids were involved in 72.2% of fatal drug overdoses. Among the cohort, 5556 (4.1%) received any MOUD and 8530 (6.2%) filled a naloxone prescription in the 12 months after the index nonfatal drug overdose. Filling a naloxone prescription (adjusted odds ratio [AOR], 0.70; 95% CI, 0.56-0.89), each percentage of days receiving methadone (AOR, 0.98; 95% CI, 0.98-0.99) or buprenorphine (AOR, 0.99; 95% CI, 0.98-0.99), and receiving behavioral health assessment or crisis services (AOR, 0.25; 95% CI, 0.22-0.28) were all associated with reduced adjusted odds of fatal drug overdose in the 12 months after the index nonfatal drug overdose.

Conclusions and Relevance  This cohort study found that, despite their known association with reduced risk of a fatal drug overdose, only a small percentage of Medicare beneficiaries received MOUD or filled a naloxone prescription in the 12 months after a nonfatal drug overdose. Efforts to improve access to behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care, are needed.