Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine

Age and racial and ethnic disparities in filled buprenorphine prescriptions post-emergency department visit in Nevada

Objectives

We described age, gender, race, and ethnicity associations with filling buprenorphine prescriptions post-emergency department (post-ED) visits.

Methods

We analyzed 1.5 years (July 1, 2020-December 31, 2021) of encounter-level Medicaid ED and retail pharmacy claims data obtained from the Nevada Department of Health and Human Services. We studied ED patients with an opioid use disorder (OUD) diagnosis who did not fill a prescription for OUD medications within 6 months before the ED encounter. Using logistic regression, we modeled the associations between the patient's demographic characteristics and the outcome, filling a buprenorphine prescription at a community pharmacy within 14 or 30 days of the ED encounter.

Results

Among 2781 ED visits, representing 2094 patients, the median age was 39 years, 54% were male, 18.5% were Black, 11.7% were Hispanic, and 62.3% were White. Only 4% of the ED visits were followed by a filled buprenorphine prescription. Increasing age (14-day window: adjusted odds ratio (aOR) = 0.965, 95% confidence interval [CI]: 0.948-0.983) and being a Black patient (14-day window: aOR: 0.114, 95% CI 0.036-0.361) were both associated with lower odds of filled buprenorphine prescriptions. These results were similar within 30 days of an ED visit.

Conclusions

Initiation of buprenorphine following an ED visit remains low among Nevadan Medicaid patients and is less likely with increasing age and among Black patients, despite strong evidence supporting its use. Overburdened EDs, lack of attention from managers, and substance use stigma are among possible explanations. When ED clinicians do write buprenorphine prescriptions, peer recovery support could increase the fill rates.

Emergency department buprenorphine program: staff concerns and recommended implementation strategies

BACKGROUND

Patients presenting to Emergency Departments (ED) with opioid use disorder may be candidates for buprenorphine treatment, making EDs an appropriate setting to initiate this underused, but clinically proven therapy. Hospitals are devoting increased efforts to routinizing buprenorphine initiation in the ED where clinically appropriate, with the greatest successes occurring in academic medical centers. Overall, however, clinician participation in these efforts is suboptimal. Hospitals need more information to inform the standardized implementation of these programs nationally. Using an implementation science framework, we investigated ED providers' concerns about ED buprenorphine programs and their willingness to prescribe buprenorphine in the ED.

METHODS

We conducted Consolidated Framework for Implementation Research (CFIR)-informed interviews with 11 ED staff in Nevada and analyzed the transcripts using a six-step thematic approach. Results were organized within the CFIR 1.0 domains of inner setting, outer setting, intervention characteristics, and individual characteristics; potential implementation strategies were recommended.

RESULTS

Physicians expressed that the ED is a suitable location for prescribing buprenorphine. However, they expressed concerns about: information gaps in the prescribing protocols (inner setting), patient outcomes beyond the ED, buprenorphine effectiveness and appropriate timing of treatment initiation (intervention characteristics), and their own competence in managing opioid withdrawal (individual characteristics). Some were anxious about patients' outcomes and continuity of care in the community (outer setting), others desired access to prospective data that demonstrate buprenorphine effectiveness. Additional concerns included a lack of availability of the required support to prescribe buprenorphine, a lack of physicians' experience and competence, and concerns about opioid withdrawal. Recommended implementation strategies to address these concerns include: designating personnel at the ED to bridge the information gap, engaging emergency physicians through educational meetings, creating a community of practice, facilitating mentorship opportunities, and leveraging existing collaborative learning platforms.

CONCLUSION

Overall, physicians in our study believed that implementing a buprenorphine program in the ED is appropriate, but had concerns. Implementation strategies could be deployed to address concerns at multiple levels to increase physician willingness and program uptake.

Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol

BACKGROUND

Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study.

METHODS

This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement.

DISCUSSION

Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality.

TRIAL REGISTRATION

ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991 .

Trends and Disparities in Initiation of Buprenorphine in US Emergency Departments, 2013-2022

This cross-sectional study assesses trends in buprenorphine initiation in US emergency departments and demographic and socioeconomic factors associated with its initiation.

Treatment Failure Versus Failed Treatments: The Risks of Embracing Treatment Refractory Addiction

ABSTRACT

In this issue, Strain advocates for the field of addiction medicine to consider a new diagnostic signal-treatment-refractory addiction. Also in this issue, Nunes and McLellan support the concepts advanced by Strain. I provide an alternate view and propose that it is premature to create such a signal and that doing so could lead to unintended adverse consequences. My argument is based on 4 concerns: (1) the lack of neuroscientific correlates, (2) the profound impact that context has on what patients receive as "treatment," (3) the rare provision of sequentially stepped treatment, and (4) the potential for misuse of the signal. Addiction medicine should be cautious in introducing concepts such as treatment-refractory addiction to ensure that patients are not seen as "treatment failures." Our efforts should rather focus on the development of additional effective treatments, improving access to existing effective treatments and a creating a system that does not provide "failed treatments."

A National Survey of Pediatric Emergency Medicine Clinicians' Comfort Level, Beliefs, and Experiences With Initiating Buprenorphine in the Emergency Department

INTRODUCTION

The prevalence of opioid use disorder (OUD) among adolescents has seen an alarming rise, prompting an exploration of the utilization of buprenorphine as a treatment modality. This study aimed to understand the perceptions, experiences, and comfort levels of pediatric emergency medicine (PEM) clinicians in initiating medication-assisted treatment (MAT) for pediatric patients presenting with OUD in emergency departments.

METHODS

Utilizing a cross-sectional survey design, data from 110 respondents were collected from a potential participant pool of 3062 for a response rate of 3.6%. The survey assessed demographics, clinical encounters, comfort levels, and opinions concerning the use of buprenorphine in the pediatric emergency setting.

RESULTS

Only 3.6% of respondents frequently evaluated and treated opioid withdrawal in the ED. A significant majority, 87.3%, indicated they had never prescribed buprenorphine for patients under 18 in the ED. While 53% of clinicians believed in initiating buprenorphine for adolescents with OUD in the ED, 33.6% expressed feeling "very uncomfortable" with the initiation process. Training in MAT appeared to influence attitudes and comfort levels significantly.

CONCLUSIONS

In this convenience sample survey with a 3.6% response rate, we found that a pronounced discomfort exists among PEM clinicians in initiating MAT, predominantly rooted in a lack of experience. Addressing this barrier through comprehensive training, developing evidence-based protocols, and fostering interdisciplinary collaboration is imperative to ensure optimal care for adolescents with OUD in emergency settings.

Evaluation of medications used for opioid use disorder in emergency departments: A cross-sectional analysis of the 2020 National Hospital Ambulatory Medical Care Survey

INTRODUCTION

Opioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs.

METHODS

NHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18-64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI.

RESULTS

There was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0-128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33-241.90) and Western region (OR43.77, 95%CI 2.97-645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001-0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41-152.33; OR: 13.84, 95%CI: 3.58-53.51, respectively).

CONCLUSION

Our study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift.

Initiation of Buprenorphine in the Emergency Department: A Survey of Emergency Clinicians

Introduction

Initiation of buprenorphine for opioid use disorder (OUD) in the emergency department (ED) is supported by the American College of Emergency Physicians and is shown to be beneficial. This practice, however, is largely underutilized.

Methods

To assess emergency clinicians' attitudes and readiness to initiate buprenorphine in the ED we conducted a cross-sectional, electronic survey of clinicians (attendings, residents, and non-physician clinicians) in a single, academic ED of a tertiary-care hospital, which serves a rural population. Our survey aimed to assess emergency clinicians' attitudes toward and readiness to initiate buprenorphine in the ED and identify clinician-perceived facilitators and barriers. Our survey took place after the initiation of the IMPACT (Initiation of Medication, Peer Access, and Connection to Treatment) project.

Results

Our results demonstrated the level of agreement that buprenorphine prescribing is within the emergency clinician's scope of practice was inversely correlated to average years in practice (R2 = 0.93). X-waivered clinicians indicated feeling more prepared to administer buprenorphine in the ED R2 = 0.93. However, they were not more likely to report ordering buprenorphine or naloxone in the ED within the prior three months. Those who reported having a family member or close friend with substance use disorder (SUD) were not more likely to agree buprenorphine initiation is within the clinician's scope of practice (P = 0.91), nor were they more likely to obtain an X-waiver (P = 0.58) or report ordering buprenorphine or naloxone for patients in the ED within the prior three months (P = 0.65, P = 0.77). Clinicians identified availability of pharmacists, inpatient/outpatient referral resources, and support staff (peer recovery support specialists and care managers) as primary facilitators to buprenorphine initiation. Inability to ensure follow-up, lack of knowledge of available resources, and insufficient education/preparedness were primary barriers to ED buprenorphine initiation. Eighty-three percent of clinicians indicated they would be interested in additional education regarding OUD treatment.

Conclusion

Our data suggests that newer generations of emergency clinicians may have less hesitancy initiating buprenorphine in the ED. In time, this could mean increased access to treatment for patients with OUD. Understanding clinician-perceived facilitators and barriers to buprenorphine initiation allows for better resource allocation. Clinicians would likely further benefit from additional education regarding medications for opioid use disorder (MOUD), available resources, and follow-up statistics.

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation

INTRODUCTION

Despite sustained efforts to reduce opioid-related overdose fatalities, rates have continued to rise. In many areas, overdose response involves emergency medical service (EMS) personnel administering naloxone and transporting patients to the emergency department (ED). However, a substantial number of patients decline transport, and many EDs do not provide medication for opioid use disorder (MOUD). One approach to filling this gap involves delivering MOUD to overdose patients in the field with trained post-overdose EMS teams who can initiate buprenorphine. In this MOUD field initiation pilot program, a trained EMS Community Paramedicine team initiates buprenorphine in the field and links patients to care. The program includes three pathways to treatment with the first designed for EMS to initiate buprenorphine after overdose reversal when the patient is in withdrawal from naloxone; a second pathway initiates buprenorphine after overdose when the patient is not in withdrawal; and a third enables self-referral via a connection to the community EMS team not necessarily related to a recent overdose.

METHODS

We conducted a retrospective cohort study of the MOUD field initiation pilot program. Data are from 28 patients who entered care immediately post-overdose initiation of buprenorphine, 21 patients who initiated on buprenorphine while not in naloxone withdrawal, and 37 patients who self-referred to treatment following outreach efforts by paramedicine and peer support professionals.

RESULTS

A total of 118 patients initiated buprenorphine during the 12-month study period and 104 (83 %) visited the clinic for their first appointment. Over two thirds (68 %, n = 80) remained engaged in care after 30 days. Retained patients tended to be male, white, uninsured, food insecure, have unstable housing, lack reliable transportation, and report prior involvement with the criminal legal system.

CONCLUSION

The initial 12-month period of the pilot program demonstrated the feasibility of initiating buprenorphine at the site of overdose without requiring transport to the ED and offer self-referral pathways for people experiencing barriers to treatment. Specialized EMS can play a critical role in expanding access to MOUD treatment by bridging the gap between overdose and comprehensive community-based care.

Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal

Importance

Buprenorphine is an effective yet underused treatment for opioid use disorder (OUD).

Objective

To evaluate the feasibility (acceptability, tolerability, and safety) of 7-day injectable extended-release buprenorphine in patients with minimal to mild opioid withdrawal.

Design, Setting, and Participants

This nonrandomized trial comprising 4 emergency departments in the Northeast, mid-Atlantic, and Pacific geographic areas of the US included adults aged 18 years or older with moderate to severe OUD and Clinical Opiate Withdrawal Scale (COWS) scores less than 8 (minimal to mild), in which scores range from 0 to 7, with higher scores indicating increasing withdrawal. Exclusion criteria included methadone-positive urine, pregnancy, overdose, or required admission. Outcomes were assessed at baseline, daily for 7 days by telephone surveys, and in person at 7 days. Patient recruitment occurred between July 13, 2020, and May 25, 2023.

Intervention

Injection of a 24-mg dose of a weekly extended-release formulation of buprenorphine (CAM2038) and referral for ongoing OUD care.

Main Outcomes and Measures

Primary feasibility outcomes included the number of patients who (1) experienced a 5-point or greater increase in the COWS score or (2) transitioned to moderate or greater withdrawal (COWS score ≥13) within 4 hours of extended-release buprenorphine or (3) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. Secondary outcomes included injection pain, satisfaction, craving, use of nonprescribed opioids, adverse events, and engagement in OUD treatment.

Results

A total of 100 adult patients were enrolled (mean [SD] age, 36.5 [8.7] years; 72% male). Among the patients, 10 (10.0% [95% CI, 4.9%-17.6%]) experienced a 5-point or greater increase in COWS and 7 (7.0% [95% CI, 2.9%-13.9%]) transitioned to moderate or greater withdrawal within 4 hours, and 2 (2.0% [95% CI, 0.2%-7.0%]) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. A total of 7 patients (7.0% [95% CI, 2.9%-13.9%]) experienced precipitated withdrawal within 4 hours of extended-release buprenorphine, which included 2 of 63 (3.2%) with a COWS score of 4 to 7 and 5 of 37 (13.5%) with a COWS score of 0 to 3. Site pain scores (based on a total pain score of 10, in which 0 indicated no pain and 10 was the worst possible pain) after injection were low immediately (median, 2.0; range, 0-10.0) and after 4 hours (median, 0; range, 0-10.0). On any given day among those who responded, between 29 (33%) and 31 (43%) patients reported no cravings and between 59 (78%) and 75 (85%) reported no use of opioids; 57 patients (60%) reported no days of opioid use. Improving privacy (62%) and not requiring daily medication (67%) were deemed extremely important. Seventy-three patients (73%) were engaged in OUD treatment on day 7. Five serious adverse events occurred that required hospitalization, of which 2 were associated with medication.

Conclusions and Relevance

This nonrandomized trial of the feasibility of a 7-day buprenorphine injectable in patients with minimal to mild opioid withdrawal (COWS scores, 0-7) found the formulation to be acceptable, well tolerated, and safe in those with COWS scores of 4 to 7. This new medication formulation could substantially increase the number of patients with OUD receiving buprenorphine.

Trial Registration

ClinicalTrials.gov Identifier: NCT04225598.

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.

The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder

BACKGROUND

Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians.

OBJECTIVE

Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision.

METHODS

From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD.

RESULTS

Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training.

CONCLUSIONS

Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.

Addressing System and Clinician Barriers to Emergency Department-initiated Buprenorphine: An Evaluation of Post-intervention Physician Outcomes

Introduction

Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions.

Methods

This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience.

Results

Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively).

Conclusion

Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.

Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process

INTRODUCTION

Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs.

METHODS

A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis.

RESULTS

A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding.

CONCLUSIONS

The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital

BACKGROUND

The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population.

METHODS

Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use.

RESULTS

From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches.

CONCLUSIONS

We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.

Performance of International Classification of Disease-10 codes in detecting emergency department patients with opioid misuse

BACKGROUND AND AIMS

Accurate case discovery is critical for disease surveillance, resource allocation and research. International Classification of Disease (ICD) diagnosis codes are commonly used for this purpose. We aimed to determine the sensitivity, specificity and positive predictive value (PPV) of ICD-10 codes for opioid misuse case discovery in the emergency department (ED) setting.

DESIGN AND SETTING

Retrospective cohort study of ED encounters from January 2018 to December 2020 at an urban academic hospital in the United States. A sample of ED encounters enriched for opioid misuse was developed by oversampling ED encounters with positive urine opiate screens or pre-existing opioid-related diagnosis codes in addition to other opioid misuse risk factors.

CASES

A total of 1200 randomly selected encounters were annotated by research staff for the presence of opioid misuse within health record documentation using a 5-point scale for likelihood of opioid misuse and dichotomized into cohorts of opioid misuse and no opioid misuse.

MEASUREMENTS

Using manual annotation as ground truth, the sensitivity and specificity of ICD-10 codes entered during the encounter were determined with PPV adjusted for oversampled data. Metrics were also determined by disposition subgroup: discharged home or admitted.

FINDINGS

There were 541 encounters annotated as opioid misuse and 617 with no opioid misuse. The majority were males (54.4%), average age was 47 years and 68.5% were discharged directly from the ED. The sensitivity of ICD-10 codes was 0.56 (95% confidence interval [CI], 0.51-0.60), specificity 0.99 (95% CI, 0.97-0.99) and adjusted PPV 0.78 (95% CI, 0.65-0.92). The sensitivity was higher for patients discharged from the ED (0.65; 95% CI, 0.60-0.69) than those admitted (0.31; 95% CI, 0.24-0.39).

CONCLUSIONS

International Classification of Disease-10 codes appear to have low sensitivity but high specificity and positive predictive value in detecting opioid misuse among emergency department patients in the United States.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Barriers and Best Practices on the Management of Opioid Use Disorder

Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

OBJECTIVE

To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs.

METHODS

We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.

RESULTS

We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.

CONCLUSIONS

Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario

BACKGROUND

Emergency department visits and hospital admissions for opioid toxicity are opportunities to initiate opioid agonist therapy (OAT), which reduces morbidity and mortality in patients with opioid use disorder (OUD). The study objectives were to evaluate OAT initiation rates after a hospital encounter for opioid toxicity in Ontario, Canada, and determine whether publication of a 2018 Canadian OUD management guideline was associated with increased initiation.

METHODS

We conducted a retrospective, population-based serial cross-sectional study of hospital encounters for opioid toxicity among patients with OUD between Jan. 1, 2013, and Mar. 31, 2020, in Ontario, Canada. The primary outcome was OAT initiation (methadone, buprenorphine-naloxone, or slow-release oral morphine) within 7 days of discharge, measured quarterly. We examined the impact of the release of the OUD management guideline on OAT initiation rates using Autoregressive Integrated Moving Average models.

RESULTS

Among 20 702 hospital visits for opioid toxicity among patients with OUD, the median age was 35 years, and 65.1% were male. Over the study period, the percentage of visits leading to OAT initiation within 7 days rose from 1.7% or less (Q1 2013) to 5.6% (Q1 2020); however, the publication of the Canadian OUD management guideline was not associated with a significant increase in these rates (0.14% slope change, 95% confidence interval -0.11% to 0.38%; p = 0.3).

INTERPRETATION

Among hospital encounters for opioid toxicity, despite rising prevalence over time, only 1 in 18 patients were dispensed OAT within a week of discharge in early 2020. These findings highlight missed opportunities to initiate therapies proven to reduce mortality in patients with OUD.

Early emergency department experience with 7-day extended-release injectable buprenorphine for opioid use disorder

As the opioid overdose epidemic escalates, there is an urgent need for treatment innovations to address both patient and clinician barriers when initiating buprenorphine in the emergency department (ED). These include insurance status, logistical challenges such as the ability to fill a prescription and transportation, concerns regarding diversion, and availability of urgent referral sites. Extended-release buprenorphine (XR-BUP) preparations such as a new 7-day injectable could potentially solve some of these issues. We describe the pharmacokinetics of a new 7-day XR-BUP formulation and the feasibility of its use in the ED setting. We report our early experiences with this medication (investigational drug CAM2038), in the context of an ongoing clinical trial entitled Emergency Department-Initiated BUP VAlidaTION (ED INNOVATION), to inform emergency clinicians as they consider incorporating this medication into their practice. The medication was approved by the European Medicines Agency in 2018 and the U.S. Food and Drug Administration in 2023 for those 18 years or older for the treatment of moderate to severe opioid use disorder (OUD). We report our experience with approximately 800 ED patients with OUD who received the 7-day XR-BUP preparation in the ED between June 2020 and July 2023.

Perspectives on and experiences of emergency department-initiated buprenorphine among clinical pharmacists: A multi-site qualitative study

INTRODUCTION

Clinical pharmacists are well positioned to enhance efforts to promote emergency department (ED)-initiated buprenorphine to treat opioid use disorder (OUD). Among clinical pharmacists in urban EDs, we sought to characterize barriers and facilitators for ED-initiated buprenorphine to inform future implementation efforts and enhance access to this highly effective OUD treatment.

METHODS

This study was conducted as a part of Project ED Health (CTN-0069, NCT03023930), a multisite effectiveness-implementation study aimed at promoting ED-initiated buprenorphine that was conducted between April 2017 and July 2020. Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) framework to assess perspectives on the relationship between 3 elements: evidence for buprenorphine, the ED context, and facilitation needs to promote ED-initiated buprenorphine. The study used an iterative coding process to identify overlapping themes within these 3 domains.

RESULTS

The study conducted eight focus groups/interviews across four geographically disparate EDs with 15 pharmacist participants. We identified six themes. Themes related to evidence included (1) varied levels of comfort and experience among pharmacists with ED-initiated buprenorphine that increased over time and (2) a perception that patients with OUD have unique challenges that require guidance to optimize ED care. With regards to context, clinical pharmacists identified: (3) their ability to clarify scope of ED care in the context of unique pharmacology, formulations, and regulations of buprenorphine to ED staff, and that (4) their presence promotes successful program implementation and quality improvement. Participants identified facilitation needs including: (5) training to promote practice change and (6) ways to leverage already existing pharmacy resources outside of the ED.

CONCLUSION

Clinical pharmacists play a unique and critical role in the efforts to promote ED-initiated buprenorphine. We identified 6 themes that can inform pharmacist-specific interventions that could aid in the successful implementation of this practice.

Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial

Importance

Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions.

Objective

To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder.

Design, Setting, and Participants

This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023.

Exposures

This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure.

Main Outcomes and Measures

Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status.

Results

A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption.

Conclusions and Relevance

In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them.

Trial Registration

ClinicalTrials.gov Identifier: NCT03658642.

Emergency Department Buprenorphine Quality Improvement and Emergency Physician Knowledge, Attitudes, and Self-Efficacy

Objective

Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency physician knowledge, confidence, and self-efficacy regarding buprenorphine prescribing and working with patients who use drugs after implementation of an ED buprenorphine quality improvement (QI) initiative.

Methods

An anonymous, online survey was administered to emergency physicians staffing four EDs in New England in 2019 and 2020 before and after an ED QI initiative. Survey questions included novel and previously validated questions to assess confidence, knowledge, self-efficacy, and attitudes about buprenorphine and working with patients who use drugs. Confidence, self-efficacy, and attitude responses were assessed on a Likert scale. Participants received a gift card for survey completion. We analyzed pre- and post- survey responses descriptively and compared them using t-tests. Using logistic regression we evaluated the factors associated with buprenorphine prescribing.

Results

Of 95 emergency physicians, 56 (58.9% response rate) completed the pre-intervention survey and 60 (63.2%) completed the post-survey. There was an increase in the number of X-waivered adult emergency physicians and ED buprenorphine prescribing after program implementation. Physician confidence increased from a mean of 3.4 (SD 0.8) to 3.9 (SD 0.7; scale 1-5, p < 0.01). Knowledge about buprenorphine increased from a mean score of 1.4 (SD 0.7) to 1.7 (SD 0.5, p < 0.01). Physician attitudes and self-efficacy did not change. Post-initiative, increased confidence was associated with higher odds of buprenorphine prescribing (odds ratio 4.4; 95% confidence interval 1.07-18.4).

Conclusion

After an ED QI initiative, buprenorphine prescribing in the ED increased, as did both physician confidence in working with patients who use drugs and their knowledge of buprenorphine. Increased confidence was associated with higher odds of buprenorphine prescribing and should be a focus of future, buprenorphine implementation strategies in the ED.

Impact of an Educational Intervention on Hospital Pharmacists' Knowledge and Application of Substance Withdrawal Management

Background

Patients with substance use disorders are often encountered in an acute care setting and withdrawal management is important. Available literature reveals inadequate acute management of substance withdrawal due to lack of experience and knowledge of medications.

Methods

A quality improvement project was implemented to improve hospital pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management through provision of didactic and case-based education and implementation of practice based prospective drug utilization review (PDUR). Pharmacists' knowledge of the management of alcohol and opioid withdrawal was assessed by a 10-item survey pre-and post-intervention.

Results

Twenty-one pharmacists completed the education and pre- and post-surveys. Scores for the 21 pharmacists improved significantly, with pre- and post-intervention scores of 7.33 ± 1.98 and 8.86 ± 0.91, respectively (P = .0035). Most pharmacists completed their required PDUR submission, and several pharmacist interventions were made and accepted post-education. Pharmacists indicated that the education increased their confidence and enabled them to learn new information that could be directly applied to their pharmacy practice.

Conclusion

Providing education and requiring a PDUR improved pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management. Re-education or expanded education may be warranted to further increase pharmacists' competence.

Barriers to initiate buprenorphine and methadone for opioid use disorder treatment with postdischarge treatment linkage

BACKGROUND

Hospitals are an essential site of care for people with opioid use disorder (OUD). Buprenorphine and methadone are underutilized in the hospital.

OBJECTIVES

Characterize barriers to in-hospital buprenorphine or methadone initiation to inform implementation strategies to increase OUD treatment provision.

DESIGN, SETTINGS, AND PARTICIPANTS

Survey of hospital-based clinicians' perceptions of OUD treatment from 12 hospitals conducted between June 2022 and August 2022.

MEASURES

Survey questions were grouped into six domains: (1) evidence to treat OUD, (2) hospital processes to treat OUD, (3) buprenorphine or methadone initiation, (4) clinical practices to treat OUD, (5) leadership prioritization of OUD treatment, and (6) job satisfaction. Likert responses were dichotomized and associations between "readiness" to initiate buprenorphine or methadone and each domain were assessed.

RESULTS

Of 160 respondents (60% response rate), 72 (45%) reported higher readiness to initiate buprenorphine compared to methadone, 55 (34%). Respondents with higher readiness to initiate medications for OUD were more likely to perceive that evidence supports the use of buprenorphine and methadone to treat OUD (p < .001), to perceive fewer barriers to treat OUD (p < .001), to incorporate OUD treatment into their clinical practice (p < .001), to perceive leadership support for OUD treatment (p < .007), and to have great job satisfaction (p < .04). Clinicians reported that OUD treatment protocols with treatment linkage, increased education, and addiction specialist support would facilitate OUD treatment provision.

CONCLUSION

Interventions that incorporate protocols to initiate medications for OUD, include addiction specialist support and education, and ensure postdischarge OUD treatment linkage could facilitate hospital-based OUD treatment provision.

Perspectives on contingency management for alcohol use and alcohol-associated conditions among people in care with HIV

BACKGROUND

Contingency management (CM) is an evidence-based approach for reducing alcohol use; however, its implementation into routine HIV primary care-based settings has been limited. We evaluated perspectives on implementing CM to address unhealthy alcohol use and associated conditions for people with HIV in primary care settings.

METHODS

From May 2021 to August 2021, we conducted two focus groups with staff involved in delivering the intervention (n = 5 Social Workers and n = 4 Research Coordinators) and individual interviews (n = 13) with a subset of participants involved in the multi-site Financial Incentives, Randomization, and Stepped Treatment (FIRST) trial. Qualitative data collection and analyses were informed by the Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework, including evidence (perception of CM), context (HIV primary care clinic and CM procedures), and facilitation (feasibility outside the research setting).

RESULTS

Several major themes were identified. Regarding the evidence, participants lacked prior experience with CM, but the intervention was well received and, by some, perceived to lead to lasting behavior change. Regarding the clinical context for the reward schedule, the use of biochemical testing, specifically fingerstick phosphatidylethanol testing, and the reward process were perceived to be engaging and gratifying for both staff and patients. Participants indicated that the intervention was enhanced by its co-location within the HIV clinic. Regarding facilitation, participants suggested addressing the intervention's feasibility for non-research use, simplifying the reward structure, and rewarding non-abstinence in alcohol use.

CONCLUSIONS

Among patients and staff involved in a clinical trial, CM was viewed as a helpful, positive, and feasible approach to addressing unhealthy alcohol use and related conditions. To enhance implementation, future efforts may consider simplified approaches to the reward structure and expanding rewards to non-abstinent reductions in alcohol consumption.

Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis

STUDY OBJECTIVE

Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs.

METHODS

We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls.

RESULTS

There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls.

CONCLUSION

An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.

Medicare coverage of buprenorphine-naloxone film surrounding generic entry

OBJECTIVES

To investigate trends in Medicare coverage of buprenorphine-naloxone film before and after the FDA approval of its first generic versions.

STUDY DESIGN

This study used data from the Part D Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information Files from 2015 to 2022, which provide information on all stand-alone Medicare/Medicare Advantage Prescription Drug Plans.

METHODS

We examined the percentage of plans that provided coverage of brand-name and generic buprenorphine-naloxone films with strength 8 mg/2 mg during 2015-2022. Median out-of-pocket (OOP) cost for a 30-day supply was estimated among all plans that provided coverage.

RESULTS

Generic buprenorphine-naloxone film was covered by 82% of Medicare Part D plans in 2020, 2 years after market entry. Coverage of brand-name Suboxone film decreased from 76% in 2019 to 42% in 2020. The median OOP cost of buprenorphine-naloxone films faced by Medicare enrollees decreased from $99 in 2019 to $42 in 2020, driven by the lower price of generic films. In contrast, the OOP cost for brand-name buprenorphine-naloxone film increased gradually from $85 in 2015 to $100 in 2022.

CONCLUSIONS

Medicare Part D plan formularies replaced brand-name buprenorphine-naloxone films with the newly approved generic versions. This was accompanied by a substantial decrease in estimated OOP cost faced by Part D enrollees. These changes could potentially increase access to buprenorphine among Medicare enrollees with opioid use disorder.

Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems

BACKGROUND

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

METHODS

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

RESULTS

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

CONCLUSIONS

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

Buprenorphine After Nonfatal Opioid Overdose: Reduced Mortality Risk in Medicare Disability Beneficiaries

INTRODUCTION

Opioid-involved overdose mortality is a persistent public health challenge, yet limited evidence exists on the relationship between opioid use disorder treatment after a nonfatal overdose and subsequent overdose death.

METHODS

National Medicare data were used to identify adult (aged 18-64 years) disability beneficiaries who received inpatient or emergency treatment for nonfatal opioid-involved overdose in 2008-2016. Opioid use disorder treatment was defined as (1) buprenorphine, measured using medication days' supply, and (2) psychosocial services, measured as 30-day exposures from and including each service date. Opioid-involved overdose fatalities were identified in the year after nonfatal overdose using linked National Death Index data. Cox proportional hazards models estimated the associations between time-varying treatment exposures and overdose death. Analyses were conducted in 2022.

RESULTS

The sample (N=81,616) was mostly female (57.3%), aged ≥50 years (58.8%), and White (80.9%), with a significantly elevated overdose mortality rate, compared with the general U.S. population (standardized mortality ratio=132.4, 95% CI=129.9, 135.0). Only 6.5% of the sample (n=5,329) had opioid use disorder treatment after the index overdose. Buprenorphine (n=3,774, 4.6%) was associated with a significantly lower risk of opioid-involved overdose death (adjusted hazard ratio=0.38, 95% CI=0.23, 0.64), but opioid use disorder-related psychosocial treatment (n=2,405, 2.9%) was not associated with risk of death (adjusted hazard ratio=1.18, 95% CI=0.71, 1.95).

CONCLUSIONS

Buprenorphine treatment after nonfatal opioid-involved overdose was associated with a 62% reduction in the risk of opioid-involved overdose death. However, fewer than 1 in 20 individuals received buprenorphine in the subsequent year, highlighting a need to strengthen care connections after critical opioid-related events, particularly for vulnerable groups.

Demographics and Clinical Characteristics of Patients With Opioid Use Disorder and Offered Medication-Assisted Treatment in the Emergency Department

Background and objective The opioid use disorder (OUD) epidemic is a persistent public health crisis in the United States. Medication-assisted treatment (MAT) with opioid agonists, including buprenorphine, is an effective treatment and is commonly initiated in the emergency department (ED). This study describes the demographics and clinical characteristics of OUD patients presenting to the ED and evaluated for MAT. Methodology A retrospective, single-center descriptive study of 129 adult patients presenting to the ED between July 2018 and July 2020 with OUD and evaluated for MAT. Results A total of 129 patients were assessed for MAT. About half (53%) received MAT; the remaining received only a referral (35%) or declined any intervention (12%). The median age was 36 years interquartile range (IQR, 28-46 years) and predominantly male (73%), single (65%), white (73%), unemployed (57%) with public insurance (55%), and without a primary care physician (58%). Majority of the patients presented with opioid withdrawal (62%) or intoxication (15%), while 23% presented with other complaints. About half of the patients (51%) were discharged with a naloxone kit. The majority of the patients were induced with buprenorphine with 4 mg or less (54%) and only 6% of patients received repeat dosing. Conclusions Male, white patients who are unmarried and unemployed, lack primary care follow-up, and rely on public insurance are more likely to be candidates for MAT. Providers should always maintain a high suspicion of opioid misuse and optimize treatment for those in withdrawal. Understanding these characteristics in conjunction with recent health policy changes will hopefully guide and encourage ED-initiated interventions in combating the opioid crisis.

A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care

Background

Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC.

Methods

A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems.

Results

Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access).

Conclusions

This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

Hospital-based clinicians lack knowledge and comfort in initiating medications for opioid use disorder: opportunities for training innovation

BACKGROUND

Hospital-based clinicians infrequently initiate medications for opioid use disorder (MOUD) for hospitalized patients. Our objective was to understand hospital-based clinicians' knowledge, comfort, attitudes, and motivations regarding MOUD initiation to target quality improvement initiatives.

METHODS

General medicine attending physicians and physician assistants at an academic medical center completed questionnaires eliciting barriers to MOUD initiation, including knowledge, comfort, attitudes and motivations regarding MOUD. We explored whether clinicians who had initiated MOUD in the prior 12 months differed in knowledge, comfort, attitudes, and motivations from those who had not.

RESULTS

One-hundred forty-three clinicians completed the survey with 55% reporting having initiated MOUD for a hospitalized patient during the prior 12 months. Common barriers to MOUD initiation were: (1) Not enough experience (86%); (2) Not enough training (82%); (3) Need for more addiction specialist support (76%). Overall, knowledge of and comfort with MOUD was low, but motivation to address OUD was high. Compared to MOUD non-initiators, a greater proportion of MOUD initiators answered knowledge questions correctly, agreed or strongly agreed that they wanted to treat OUD (86% vs. 68%, p = 0.009), and agreed or strongly agreed that treatment of OUD with medication was more effective than without medication (90% vs. 75%, p = 0.022).

CONCLUSIONS

Hospital-based clinicians had favorable attitudes toward MOUD and are motivated to initiate MOUD, but they lacked knowledge of and comfort with MOUD initiation. To increase MOUD initiation for hospitalized patients, clinicians will need additional training and specialist support.

Organizational readiness to implement task-strengthening strategy for hypertension management among people living with HIV in Nigeria

BACKGROUND

Hypertension (HTN) is highly prevalent among people living with HIV (PLHIV), but there is limited access to standardized HTN management strategies in public primary healthcare facilities in Nigeria. The shortage of trained healthcare providers in Nigeria is an important contributor to the increased unmet need for HTN management among PLHIV. Evidence-based TAsk-Strengthening Strategies for HTN control (TASSH) have shown promise to address this gap in other resource-constrained settings. However, little is known regarding primary health care facilities' capacity to implement this strategy. The objective of this study was to determine primary healthcare facilities' readiness to implement TASSH among PLHIV in Nigeria.

METHODS

This study was conducted with purposively selected healthcare providers at fifty-nine primary healthcare facilities in Akwa-Ibom State, Nigeria. Healthcare facility readiness data were measured using the Organizational Readiness to Change Assessment (ORCA) tool. ORCA is based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework that identifies evidence, context, and facilitation as the key factors for effective knowledge translation. Quantitative data were analyzed using descriptive statistics (including mean ORCA subscales). We focused on the ORCA context domain, and responses were scored on a 5-point Likert scale, with 1 corresponding to disagree strongly.

FINDINGS

Fifty-nine healthcare providers (mean age 45; standard deviation [SD]: 7.4, 88% female, 68% with technical training, 56% nurses, 56% with 1-5 years providing HIV care) participated in the study. Most healthcare providers provide care to 11-30 patients living with HIV per month in their health facility, with about 42% of providers reporting that they see between 1 and 10 patients with HTN each month. Overall, staff culture (mean 4.9 [0.4]), leadership support (mean 4.9 [0.4]), and measurement/evidence-assessment (mean 4.6 [0.5]) were the topped-scored ORCA subscales, while scores on facility resources (mean 3.6 [0.8]) were the lowest.

CONCLUSION

Findings show organizational support for innovation and the health providers at the participating health facilities. However, a concerted effort is needed to promote training capabilities and resources to deliver services within these primary healthcare facilities. These results are invaluable in developing future strategies to improve the integration, adoption, and sustainability of TASSH in primary healthcare facilities in Nigeria.

TRIAL REGISTRATION

NCT05031819.

Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study

BACKGROUND

Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations.

METHODS

We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns.

RESULTS

Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine.

CONCLUSION

The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

BACKGROUND

Emergency Departments (EDs) have become critical 'touchpoints' for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients' ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients' experiences with ED staff.

METHODS

This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants' ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization.

RESULTS

Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care.

CONCLUSIONS

While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose.

TRIAL REGISTRATION

Clinical trial registration: NCT03684681.

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder

Importance

Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.

Objective

To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.

Design, Setting, and Participants

This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.

Exposure

A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.

Main Outcomes and Measures

The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.

Results

A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).

Conclusions and Relevance

In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.

Trial Registration

ClinicalTrials.gov Identifier: NCT03023930.

Variability in opioid use disorder clinical presentations and treatment in the emergency department: A mixed-methods study

BACKGROUND

There is strong evidence for emergency department (ED)-initiated treatment of opioid use disorder (OUD). However, implementation is variable, and ED management of OUD may differ by clinical presentation. Our aim was to use mixed methods to explore variation in ED-based OUD care by patient clinical presentation and understand barriers and facilitators to ED implementation of OUD treatment across scenarios.

METHODS

We analyzed treatment outcomes in OUD-related visits within three urban, academic EDs from 12/2018 to 7/2020 following the implementation of interventions to increase ED-initiated OUD treatment. We assessed differences in treatment with medications for OUD (MOUDs) by clinical presentation (overdose, withdrawal, others). These data were integrated with results from 5 focus groups conducted with 28 ED physicians and nurses January to April 2020 to provide a richer understanding of clinician perspectives on caring for ED patients with OUD.

RESULTS

Of the 1339 total opioid-related visits, there were 265 (20%) visits for overdose, 123 (9%) for withdrawal, and 951 (71%) for other OUD-related conditions. 23% of patients received MOUDs during their visit or at discharge. Treatment with MOUDs was least common in overdose presentations (6%) and most common in withdrawal presentations (69%, p < 0.001). Buprenorphine was prescribed at discharge in 15% of visits, including 42% of withdrawal visits, 14% of other OUD-related visits, and 5% of overdose visits (p < 0.001). In focus groups, clinicians highlighted variation in ED presentations among patients with OUD. Clinicians also highlighted key aspects necessary for successful treatment initiation including perceived patient receptivity, provider confidence, and patient clinical readiness.

CONCLUSIONS

ED-based treatment of OUD differed by clinical presentation. Clinician focus groups identified several areas where targeted guidance or novel approaches may improve current practices. These results highlight the need for tailored clinical guidance and can inform health system and policy interventions seeking to increase ED-initiated treatment for OUD.

Enhancing Use of Medications for Opioid Use Disorder Through External Coaching

OBJECTIVE

This randomized controlled trial tested whether external coaching influences addiction treatment providers' utilization of medications to treat opioid use disorder (MOUDs).

METHODS

This study recruited 75 unique clinical sites in Florida, Ohio, and Wisconsin, including 61 sites in specialty treatment agencies and 14 behavioral health sites within health systems. The trial used external coaching to increase use of MOUDs in the context of a learning collaborative and compared it with no coaching and no learning collaborative (control condition). Outcome measures of MOUD capacity and utilization were monthly tabulations of licensed buprenorphine slots (i.e., the number of patients who could be treated based on the buprenorphine waiver limits of the site's providers), buprenorphine use, and injectable naltrexone administration.

RESULTS

The coaching and control arms showed no significant difference at baseline. Although buprenorphine slots increased in both arms during the 30-month trial, growth increased twice as fast at the coaching sites, compared with the control sites (average monthly rate of 6.1% vs. 3.0%, respectively, p<0.001). Buprenorphine use showed a similar pattern; the monthly growth rate in the coaching arm was more than twice the rate in the control arm (5.3% vs. 2.4%, p<0.001). Coaching did not have an impact on injectable naltrexone, which grew less than 1% in both arms over the trial period.

CONCLUSIONS

External coaching can increase organizational capacity for and growth of buprenorphine use. Future research should explore the dimensions of coaching practice, dose, and delivery modality to better understand and enhance the coaching function.

Peer recovery coaches and emergency department utilization in patients with substance use disorders

BACKGROUND

Although Emergency Departments (ED) frequently provide care for patients with substance use disorders (SUD), there are many barriers to connecting them with appropriate long-term treatment. One approach to subside risk in this population is the Peer Recovery Coach (PRC). PRCs are individuals with a lived experience of the rehabilitation process and are a powerful resource to bridge this gap in care by engaging patients and their families and providing system navigation, self-empowerment for behavior change, and harm reduction strategies. The purpose of this project is to describe an ED-based PRC program, evaluating its feasibility and efficacy.

METHODS

This was a retrospective quality improvement project conducted at 3 suburban hospitals. All patients arriving to the ED were screened with a brief questionnaire in triage and patients identified as a high-risk had referral placed to a PRC if the patient consented. The PRC met with the patient at the ED bedside if possible. The PRC program members collected prospective data on patient engagement with the PRC at 30, 60, and 90 days post ED encounter. Using the EMR we identified the number of subsequent ED visits at 30, 60, and 90 days (for both medical and substance use disorder-related visits) from the index PRC visit.

RESULTS

There were 448 individuals identified and included in this analysis between January 1, 2019 and June 30, 2020, of which 292 (66%) were male and the mean age was 44 (range 18-80). Most patients identified alcohol as the primary substance they used (289, 65%), followed by heroin/opiates (20%). At 30, 60, and 90 days, there were 110 (25%), 79 (18%), and 71 (16%) patients who were still actively engaged in the program, respectively. Among all patients in the cohort, there was essentially no decrease in mean visits before versus after the PRC engagement visit. However, among patients who had at least one prior ED visit, there were significant differences in mean visits across all visit-types: for patients with 1 prior ED visit, 90 day mean decrease in visits = 1.0 visits (95% CI 0.7-1.2), for patients with 5+ prior ED visits, 90 day mean decrease in visits = 3.6 visits (95% CI 2.4-4.8).

CONCLUSION

We describe the implementation of an ED-based PRC program for patients with substance use disorders. While we demonstrated that it is feasible for the PRC to engage the patient while in the ED, there was poor follow-up with the program outpatient. For patients with at least one previous SUD visit to the ED, there was a statistically significant reduction in ED utilization after engaging with a PRC while in the ED, suggesting this may be a population that could be targeted to link patients to long term care and decrease repeated ED utilization.

Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

OBJECTIVES

Safer opioid prescribing patterns, naloxone distribution, and medications for opioid use disorder (M-OUD) are an important part of decreasing opioid-related adverse events. Veterans are more likely to experience these adverse events compared to the general population. Despite treatment guidelines and ED-based opioid safety programs implemented throughout Veterans Affairs (VA) Medical Centers, many Veterans with OUD do not receive these harm reduction interventions. Prior research in other health care settings has identified barriers to M-OUD initiation and naloxone distribution; however, little is known about how this may be similar or different for health care professionals in VA ED and urgent care centers.

METHODS

We conducted qualitative interviews with VA health care professionals and staff using a semistructured interview guide. We analyzed the data addressing barriers and facilitators to M-OUD treatment in the ED and naloxone distribution using descriptive matrix analysis, followed by team consensus.

RESULTS

We interviewed 19 VA staff in various roles. Respondent concerns and considerations regarding the initiation of M-OUD in the ED included M-OUD initiation falling outside of ED's scope of providing acute treatment, lack of VA-approved M-OUD protocols and follow-up procedures, staffing concerns, and educational gaps. Respondents reported that naloxone was important but lacked clarity on who should prescribe it. Some respondents stated that an automated system to prescribe naloxone would be helpful, and others felt that it would not offer needed support and education to patients. Some respondents reported that naloxone would not address opioid misuse, which other respondents felt was a belief due to stigma around substance use and lack of education about treatment options.

CONCLUSIONS

Our VA-based research highlights similarities of barriers and facilitators, seen in other health care settings, when implementing opioid safety initiatives. Education and training, destigmatizing substance use disorder care, and leveraging technology are important facilitators to increasing access to lifesaving therapies for OUD treatment and harm reduction.

Emergency Department-Initiated Buprenorphine Treatment in a Population with a High Rate of Homelessness: An Observational Study

BACKGROUND

Buprenorphine is an effective treatment for opioid use disorders. A previous randomized trial comparing emergency department (ED)-initiated buprenorphine to standard care showed dramatic improvement in follow-up. This is encouraging, but must be replicated to understand the generalizability of buprenorphine treatment.

OBJECTIVES

Evaluate the efficacy of an ED-initiated buprenorphine protocol similar to a previous randomized trial in a different population.

METHODS

This ED-based descriptive study described the results of a project implementing an opioid use disorder treatment protocol that included buprenorphine. Patients with opioid use disorder were offered treatment with buprenorphine, a buprenorphine prescription whenever possible, and a follow-up visit to a clinic providing addiction treatment. The primary outcome was engagement in formal addiction treatment 30 days after the index visit.

RESULTS

Of the 210 patients who accepted referral for outpatient medication-assisted treatment, 95 (45.2%) achieved the primary outcome. Two-thirds of these patients received a buprenorphine prescription at discharge; 40% were homeless. A regression analysis revealed one statistically significant predictor of the primary outcome: patients who were housed were 2.49 times more likely to engage in opioid use disorder treatment than patients who were homeless (p = 0.02).

CONCLUSIONS

In this descriptive study of an ED-initiated buprenorphine protocol, follow-up was less than that reported in a previous randomized controlled trial. Two important differences between our study and the randomized trial are the high rate of homelessness and the fact that not every patient received a prescription for buprenorphine. The efficacy of ED-initiated treatment may depend on certain population characteristics.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.