When it comes to treating opioid overdoses in emergency departments, fewer than 10% of patients are offered buprenorphine or methadone - two life-saving medications for opioid use disorder (MOUDs) - according to a study published in The American Journal of Emergency Medicine.

Since 2015, at least five states have passed laws requiring emergency departments to provide additional support for opioid overdose patients, such as initiating MOUD treatment. Over the next five years, Barbara "Basia" Andraka-Christou and her research team will examine whether state policies that mandate evidence-based treatments for opioid use disorder ultimately save lives.

Opioid use disorder is a life-threatening health condition that affects more than 2 million people in the U.S.

For those experiencing opioid overdose, MOUDs like buprenorphine and methadone can reduce the risk of death by 50%.

An associate professor in the College of Community Innovation and Education's School of Global Health Management and Informatics, Andraka-Christou focuses much of her research efforts on expanding access to life-saving medications for substance use disorder.

Expanding Life-Saving Care

Funded by a five-year, $3.5 million NIH grant, Andraka-Christou is collaborating with University of Michigan health economist and co-principal investigator Thuy Nguyen on this legal epidemiology project. Using policy surveillance and difference-in-difference analyses, they'll assess how state emergency department laws affect patient health outcomes. The findings could inform broader development, refinement and implementation of similar policies, ultimately improving care for people experiencing overdose and helping prevent future overdoses.

She adds that the specific requirements of each law may make a difference. For example, an overdose patient who's handed a phone number for an addiction clinic may be less likely to connect and continue receiving treatments than someone who's provided with an MOUD in the emergency department and guided through setting up an appointment in the community, she says.

"It's one thing to start someone on MOUDs, but an emergency department is a unique setting," Andraka-Christou says. "We don't want people to have to repeat the cycle and keep going back to the emergency room. There needs to be an intermediary step - perhaps a warm handoff to a primary care doctor, an addiction clinic or a methadone clinic - so that they can continue to see that person after initial treatment. That's currently a big gray area, and outcomes can potentially depend on how prescriptive these laws are."

Building a First-Of-Its-Kind Database

Andraka-Christou and her team are creating a longitudinal database of all state statutes, regulations and executive orders effective between 2014 and 2024 related to facilitating MOUD use after emergency department visits for opioid overdose. This requires assessing thousands of laws for relevance before interpreting legal jargon, summarizing and transforming them into a quantitative policy dataset.

The team will then use three sets of claims data - Medicaid, Medicare and commercial insurance - to describe trends in MOUD initiation and retention rates after emergency department visits, examining the effects of different policies. Researchers will also comb through the data to find and describe key patient, provider, geographic and demographic characteristics associated with treatment after these visits. Such factors include rurality, income level and covariates like age or co-occurring conditions.

"With overdoses, there are so many claim codes that are relevant, such as poisoning, intoxication and overdose," Andraka-Christou says. "They're also divided by the type of opioid. Within all of these, we will also examine the type of medication that they're receiving - such as methadone, buprenorphine or naltrexone - and how any legal issues surrounding them influence retention. We'll need to look at differences in effects of the law by type of poisoning, and there might also be variation in the effects of these laws depending on each population of insurance."

Shifting How Standards of Care Are Enforced

Andraka-Christou says that at a higher level, the project should provide an interesting analysis of what happens when state law requires specific action in medicine. Instead, best practices may not occur until patients or their families initiate malpractice lawsuits for violation of the standard of care - something that also requires health literacy and legal knowledge to do. If top-down state laws in this study are found to be effective at increasing the use of evidence-based treatment, they could serve as catalysts for a paradigm shift in how quality of care is enforced in hospitals.

"If we find that the states that implemented a law requiring MOUD provision see more opioid-use disorder patients staying on the medications, that bodes well and could have massive implications for public health," she says. "At that point, there's a good argument to be made that, for this situation and population, we may need to take a more top-down approach to enforce the standard of care."

Researcher Credentials

Andraka-Christou received both her juris doctorate and doctorate in law and social science from Indiana University Bloomington. She is a licensed attorney. She joined UCF's School of Global Health Management and Informatics in 2017 and holds a joint secondary appointment in the College of Medicine. Her areas of expertise include health services, health policy and substance use disorder treatment. Andraka-Christou also leads UCF's Substance Use Policy and Evaluation research team.

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