Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions

Barriers and facilitators to buprenorphine delivery: Results from a qualitative study of syringe services provider experiences

BACKGROUND

Access to medications for opioid use disorder (MOUD) is essential for the 6.1 million Americans with OUD. However, only one in five adults with past-year OUD received MOUD. Syringe services programs (SSPs) have existing and trusting relationships with people who use drugs and are an alternative service provider to traditional healthcare settings. SSPs are uniquely positioned to facilitate buprenorphine inductions and increase overall MOUD access. We aimed to understand models for implementing buprenorphine and barriers and facilitators SSPs encounter.

METHODS

We interviewed 23 SSP representatives across the U.S. Interviews sought to explore emerging issues, including whether and how SSPs facilitate access to buprenorphine. We used purposive sampling to include programs varying by region, organizational type, and legal status to understand a range of perspectives. We coded transcripts using a blended inductive and deductive, content analysis approach, met weekly to capture emerging themes, and developed analytic memos using the Health Equity Implementation Framework.

RESULTS

Of the 23 representatives interviewed, 20 reported that their SSP facilitated buprenorphine access. We identified four models for implementing buprenorphine. For all models, stigma, policy, and funding systems dictate SSPs' ability to be involved in buprenorphine induction. In turn, these determinants impact the patient-provider buprenorphine induction experience, which could perpetuate low service provision and participant uptake.

CONCLUSIONS

SSPs need various approaches to improve the patient-provider buprenorphine induction experience. SSPs can select the best fit buprenorphine model(s) by examining their inner and outer contexts. In doing so, SSPs leverage their position as trusted allies to improve care and outcomes for people with OUD.

Racial, ethnic, and sex disparities in buprenorphine treatment from emergency departments by discharge diagnosis

OBJECTIVES

Racial and sex disparities are noted in the administration and prescribing of buprenorphine from emergency departments (EDs) nationally. It is unknown whether disparities persist when accounting for the specific discharge diagnosis addressed during encounters such as opioid overdose or withdrawal.

METHODS

We conducted a cross-sectional analysis of opioid-related ED encounters from January 2020 through December 2023 using a national database, Epic Cosmos. We analyzed the effect of opioid encounter subtype-overdose or withdrawal-on receipt of buprenorphine using multivariable logistic regression adjusting for demographics and measured confounding variables. Encounter subtypes were defined by diagnosis codes and buprenorphine receipt was defined as administration or prescribing. We evaluated for racial, ethnic, and sex disparities within encounter subtypes for withdrawal and overdose.

RESULTS

We examined 1,088,033 opioid-related encounters. Adjusted odds for buprenorphine receipt were greater for encounters involving withdrawal (odds ratio [OR] 2.22, 95% CI 2.18-2.26), though reduced for overdose (OR 0.52, 95% CI 0.51-0.53) and other opioid complications (OR 0.69, 95% CI 0.64-0.70). Males were more likely to receive buprenorphine (OR 1.18, 95% CI 1.16-1.19) than females. All racial minorities excepting American Indian/Native American patients (OR 1.04, 95% CI 1.00-1.08) were less likely to receive buprenorphine than White patients (Asian OR 0.85, 95% CI 0.79-0.81; Black OR 0.80, 95% CI 0.79-0.81; Native Hawaiian/Pacific Islander OR 0.79, 95% CI 0.71-0.89). Subtype analyses indicated decreased odds for buprenorphine receipt for female patients across all subtypes. An increased odds for buprenorphine receipt among Black patients (OR 1.04, 95% CI 1.01-1.07; ref. White race) was noted in encounters involving opioid withdrawal but disparities persisted for opioid overdose.

CONCLUSIONS

The administration and prescribing of buprenorphine in the ED is heavily influenced by the presence of opioid withdrawal. Disparities disadvantage female patients and racial minorities. Some racial disparities, particularly among Black patients, are not evident when solely considering encounters involving opioid withdrawal. System-level interventions are needed to address disparities and improve the equitable uptake of ED-initiated buprenorphine.

Implementation of an Emergency Department Opioid Use Disorder Initiative: Clinical Processes and Institution Specific Education Improve Care

BACKGROUND

Emergency department (ED) visits associated with opioid use and fatal overdoses increase annually. Emergency clinician-initiated medication for opioid use disorder (MOUD) reduces mortality and improves treatment retention.

OBJECTIVE

We describe and evaluate a program to implement MOUD at an academic ED using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

METHODS

This was a retrospective cohort study of patients presenting to the ED who were eligible for MOUD. A multipronged MOUD program consisting of electronic health record (EHR) order set, email communications, and resident education was delivered over 1 year. Clinical processes were measured before and after program implementation, including buprenorphine and naloxone utilization and outpatient referrals for treatment.

RESULTS

We identified 319 eligible encounters over the 2-year study period. Patients were predominantly non-Hispanic white men with a mean age of 40 ± 12.8 years. After program initiation, 109/189 patients (57.7%) were offered or initiated on buprenorphine, compared to 46/130 patients (35.4%) before (95% confidence interval). Protocol dosing was used in 92% of initiations. Outpatient treatment provider referrals increased from 46.1% (60/130) to 63% (119/189; 95% confidence interval). More patients in the postintervention group period requested buprenorphine during their visit compared to before the intervention (24.6% vs. 10%).

CONCLUSIONS

We observed improvements in the rate of buprenorphine prescription and outpatient treatment referrals at an academic ED following a quality improvement program implemented using the RE-AIM framework.

Effects of Stigmatizing Language on Trainees' Clinical Decision-Making in Substance Use Disorders: A Randomized Controlled Trial

OBJECTIVES

Substance use disorder (SUD) continues to be one of the most stigmatized and under-treated conditions in the United States. Stigmatizing language used by healthcare workers can transmit bias to others within healthcare, including medical trainees. This study investigates how stigmatizing language and undergraduate medical education (UME) curricula may influence trainees' clinical decision-making for patients with SUD.

METHODS

Medical students from three Chicago-area medical schools were randomized to review either a stigmatizing or neutral version of a clinical scenario describing a patient experiencing opioid withdrawal. Participants (a) selected treatment plans for the fictional patient using two multiple-choice questions, (b) completed the Medical Condition Regard Scale (MCRS) to assess their attitudes, and (c) reported prior SUD experiences, both curricular and personal. Statistical analyses explored whether treatment decisions were influenced by attitudes, addiction medicine curricula, and exposure to the stigmatizing vignette.

RESULTS

Among the 366 medical students who completed this study, exposure to stigmatizing language (n = 191) led to clinical decision-making that would be less effective in treating opioid withdrawal for the fictional patient (p = 0.027; η2 = 0.013). Exposure to more SUD education during UME was correlated with more effective clinical decision-making for opioid withdrawal (β = 0.181; R2 = 0.033; p < 0.001) but was not correlated with attitudes toward patients with SUD (p = 0.231).

CONCLUSIONS

Stigmatizing language influences clinical decision-making when treating patients with SUD. Improving SUD education within UME may be an effective strategy for mitigating this effect within medical trainees.

Identifying High-Priority Ethical Challenges for Precision Emergency Medicine: Nominal Group Study

Background

Precision medicine promises to revolutionize health care by providing the right care to the right patient at the right time. However, the emergency department's unique mandate to treat "anyone, anywhere, anytime" creates critical tensions with precision medicine's requirements for comprehensive patient data and computational analysis. As emergency departments serve as health care's safety net and provide a growing proportion of acute care in America, identifying and addressing the ethical challenges of implementing precision medicine in this setting is crucial to prevent exacerbation of existing health care disparities. The rapid advancement of precision medicine technologies makes it imperative to understand these challenges before widespread implementation in emergency care settings.

Objective

This study aimed to identify high priority ethical concerns facing the implementation of precision medicine in the emergency department.

Methods

We conducted a qualitative study using a modified nominal group technique (NGT) with emergency physicians who had previous knowledge of precision medicine concepts. The NGT process consisted of four phases: (1) silent generation of ideas, (2) round-robin sharing of ideas, (3) structured discussion and clarification, and (4) thematic grouping of priorities. Participants represented diverse practice settings (county hospital, community hospital, academic center, and integrated managed care consortium) and subspecialties (education, ethics, pediatrics, diversity, equity, inclusion, and informatics) across various career stages from residents to late-career physicians.

Results

A total of 12 emergency physicians identified 82 initial challenges during individual ideation, which were consolidated to 48 unique challenges after removing duplicates and combining related items. The average participant contributed 6.8 (SD 2.9) challenges. These challenges were organized into a framework with 3 themes: values, privacy, and justice. The framework identified the need to address these themes across 3 time points of the precision medicine process: acquisition of data, actualization in the care setting, and the after effects of its use. This systematic organization revealed interrelated concerns spanning from data collection and bias to implementation challenges and long-term consequences for health care equity.

Conclusions

Our study developed a novel framework that maps critical ethical challenges across 3 domains (values, privacy, and justice) and 3 temporal stages of precision medicine implementation. This framework identifies high-priority areas for future research and policy development, particularly around data representation, privacy protection, and equitable access. Successfully addressing these challenges is essential to realize precision medicine's potential while preserving emergency medicine's core mission as health care's safety net.

Disparities in Buprenorphine Administration for Opioid Use Disorder in the Emergency Department

STUDY OBJECTIVE

Although buprenorphine is an effective treatment for opioid use disorder (OUD), this treatment is often not universally provided in the emergency department (ED). We aimed to determine whether patient characteristics, particularly race and ethnicity, were associated with buprenorphine administration.

METHODS

This was a retrospective cross-sectional study of adult patients who had a positive screening result for opioid misuse in the ED at a single urban hospital. Univariate and multivariable logistic regressions were used to assess the association of patient characteristics (race, ethnicity, age, sex, insurance type, and Area Deprivation Index) with buprenorphine administration.

RESULTS

Of 1082 patients who screened positive for opioid misuse, 133 (12%) were treated with buprenorphine and 949 (88%) were not. Despite representing over half the patient sample, Black patients (n = 682) were less likely than White patients (n = 310) to be treated with buprenorphine (multivariable: OR, 0.56; 95% CI, 0.35-0.88; P = 0.023). Age, sex, insurance type, ethnicity, and Area Deprivation Index were not associated with buprenorphine administration.

CONCLUSIONS

Patient race was associated with buprenorphine administration, even after controlling for multiple other social determinants of health. These data suggest racial disparities in care that should be investigated through further research to optimize equitable administration of buprenorphine.

Incidence of buprenorphine-precipitated opioid withdrawal in adults with opioid use disorder: A systematic review

BACKGROUND AND AIMS

Buprenorphine is an evidence-based treatment for opioid use disorder, and the risk of precipitated withdrawal contributes to its underuse. The goal of this systematic review was to determine the incidence of buprenorphine-precipitated withdrawal in adults with opioid use disorder.

METHODS

This systematic review was registered on PROSPERO (CRD42023437634). We searched Medline, Embase Classic + Embase, and Cochrane CENTRAL from inception to 10 November 2023, and included original research that reported the incidence of sublingual buprenorphine-precipitated withdrawal in adults with opioid use disorder. Primary screening was completed by four independent reviewers. Full text review, data extraction and risk of bias assessments using the Newcastle Ottawa Scale and the Cochrane Risk of Bias 2 tool were completed by two independent reviewers. The primary outcome was precipitated withdrawal. Secondary outcomes were baseline opioids used, induction dose, initial Clinical Opiate Withdrawal Scale (COWS) score, location of induction, definition and severity of precipitated withdrawal and adverse events. The range of incidence of precipitated withdrawal across studies was described.

RESULTS

Our search yielded 10 197 unique citations. Twenty-one cohort and five randomized trials met inclusion criteria (n = 4497, range 20-1293). The overall incidence of precipitated withdrawal ranged from 0 to 13.2%. Nine studies defined precipitated withdrawal; definitions were inconsistent. Most patients used heroin at baseline. The most common initial dose of buprenorphine was between 2 mg and 8 mg (range: 0.075 mg-24 mg). Initial minimum COWS score ranged from 5 to 13. Induction locations included home, inpatient, emergency department, pre-hospital, outpatient and residential units. Of the fifteen studies with cases of precipitated withdrawal, nine studies did not report the severity of withdrawal experienced. Other induction-related adverse events varied. The overall quality of included studies was poor.

CONCLUSIONS

The best available evidence suggests the incidence of buprenorphine-precipitated withdrawal in adults with opioid use disorder is low and should not be a barrier to use.

Attitudes, Beliefs, Barriers, and Facilitators of Emergency Department Nurses Toward Patients with Opioid Use Disorder and Naloxone Distribution

Introduction

As opioid overdose deaths continue to rise, the emergency department (ED) remains an important point of contact for many at risk for overdose. In this study our purpose was to better understand the attitudes, beliefs, and knowledge of ED nurses in caring for patients with opioid use disorder (OUD). We hypothesized a difference in training received and attitudes toward caring for patients with OUD between nurses with <5 years and ≥6 years of clinical experience.

Methods

We conducted a survey among ED nurses in a large academic medical center from May-July 2022. All ED staff nurses were surveyed. Data entry instruments for the nursing surveys were programmed in Qualtrics, and we analyzed results R using a chi-square test or Fisher exact test to compare nurses with <5 years and ≥6 years of clinical experience. A P-value of < 0.05 was considered statistically significant.

Results

We distributed 74 surveys, and 69 were completed (93%). Attitudes toward naloxone distribution from the ED were positive, with 72% of respondents reporting they were "very" or "extremely" supportive of distributing naloxone kits to individuals at risk of overdose. While attitudes were positive, barriers included limited time, lack of system support, and cost. Level of comfort in caring for patients with OUD was high, with 78% of respondents "very" or "extremely" comfortable. More education is needed on overdose education and naloxone distribution (OEND) with respondents 38% and 45% "a little" or "somewhat" comfortable, respectively. Nurses with <5 years of experience reported receiving more training on OEND in nursing school compared to those with ≥6 years of experience (P = 0.03). There were no significant differences in reported attitudes, knowledge, or comfort in caring for patients with OUD.

Conclusion

In this single-center survey, we found ED nurses were supportive of overdose education and naloxone distribution. There are opportunities for targeted education and addressing systemic barriers to OEND. All interventions should be evaluated to gauge impact on knowledge, attitudes, and behaviors.

Overview of best practices for buprenorphine initiation in the emergency department

In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.