This review reemphasizes the disproportionate social need and risk which impact the OUD population, particularly those seen in an ED setting. High rates of socioeconomic disparities, including homelessness, unemployment, and financial insecurity, were noted in this study cohort at intake. A previous cross-sectional study considering zip-code level socioeconomic factors (poverty, unemployment, educational attainment, and income) in 17 states across the US, showed elevated rates of opioid overdose in economically disadvantaged zip codes.14 Yamamoto et al., considered homelessness as a factor in ED patients specifically, and demonstrated a significant association between opioid overdose and opioid-related ED visits and homelessness, even when controlling for low income.15 These inequities may be attributed to upstream social disadvantages, including restricted economic opportunities and limited access to primary or preventive healthcare. The resultant environment has been shown to foster drug use, including the abuse of opioids.16 It also follows that the associated life stressors and despair associated with this environmental context results in depressed subjectively-reported psychosocial QoL variables (i.e. interpersonal relationships, self-rating of QoL, etc.), as was noted in our study subjects at intake.
Engagement, however, in MOUD treatment and referral services, did result in a subsequent significant improvement for the majority of QoL factors assessed. Subjectively reported psychosocial variables appeared to be more consistently impacted than objective variables. This favor toward psychosocial factors may be, in part, due to the fact that social relationship and psychological variables may lend themselves to a more dynamic and rapid response than the assessed objective variables. Patients engaged in regular health care for chronic disease management, to encompass OUD, have been demonstrated to report improved overall wellness and health perceptions, even after only short time periods in treatment.17 Similar improvement in social relationship and psychological domains with MOUD treatment has been demonstrated in the outpatient-initiation setting previously.18 Interestingly, ‘friend/family support/contact’ did not improve, although, it was rated relatively high amongst our subjects at intake, almost 80%. Family and social network support have been shown to be important for treatment retention and adherence outcomes, however, this network for many individuals with OUD often encompasses drug-using friends.19 Engagement in a treatment program may isolate them from this network. Similarly, many individuals with OUD may find relationships with family strained from previous conflict, often related to their OUD.
Objective variables considered in this review were less likely to demonstrate change. These factors, including housing, education and employment, may require more than six months to evidence significant change; therefore, impact on these factors may not have been adequately captured. It is certainly possible that these factors may see notable improvement over the course of a longer treatment or follow-up timeframe. ‘Financial needs’ was one objective factor which did significantly improve. This may be related to a number of factors associated with OUD treatment including less money spent on illicit drugs and more productive hours spent at work, for instance; while not significant, rates of employment were increased at three- and six-months as compared to intake, which may also directly impact financial security.
It is also notable that our study population demonstrated a high rate of violence exposure at intake, nearly three-quarters of respondents, even higher among women (85.7%). Unfortunately, similarly high rates of violence have been previously reported among substance users.20 The gender discrepancy is also roughly consistent with national statistics on domestic and interpersonal violence;21 while both men and women experience violence, a larger percentage of these victims are female. The ‘exposure to violence’ percentages did improve with the MOUD intervention, however, was not a statistically significant. This trend may represent another example of a QoL factor that may see improvement over a longer timeframe of MOUD treatment, although, ‘exposure to violence’ is likely influenced by challenging domestic and environmental factors that may be difficult to address solely via OUD management. In prior studies, women have attributed a high level of domestic violence to partners who have OUD, which could influence future MOUD treatment to target all household members in order to effectively raise overall QoL.22
It is unclear why, in our study, men reported higher overall levels of energy compared to women, and African Americans higher than Caucasians. Sociocultural norms and expectations may play into gender-reported differences. Certainly ‘energy levels’ and ‘energy for everyday life’ may be a QoL factor that gains more clarity with a longer research timeframe, as energy and physical health are often the product of improving other areas of one’s life.