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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Description and Evaluation of Practice-Based Training in OUD Care for Hospital-Based Generalist Physicians

BACKGROUND

Hospitalizations are important opportunities to deliver evidence-based opioid use disorder (OUD) care, yet most hospital-based generalist physicians receive minimal OUD training. We describe a novel OUD training for generalists and mixed-methods evaluation in a large urban hospital.

METHODS

Training Description: Hospital-based generalist physicians received a single, 1-hour, small-group, in-person OUD training (OUD diagnosis, initiating medications for OUD [MOUD], and discharge planning) and post-training support. Evaluation: We examined self-reported changes in knowledge, confidence, skill, and frequency of providing OUD care; barriers and facilitators to applying training skills; and suggestions for training modification. Data collection included the following: (1) end-of-training questionnaires; (2) 12-month follow-up questionnaires (retrospective pre-post-design); and (3) qualitative interviews and a focus group. Stuart Maxwell tests were used to examine pre-/post-differences in knowledge, confidence, and skill. Rapid qualitative analysis identified barriers and facilitators to applying training skills.

RESULTS

Nineteen generalist physicians participated, with 11 (58%) providing 12-month follow-up data. At 12 months, compared to pre-training, more participants agreed or highly agreed that after the training, they had adequate knowledge (100% vs 44%), confidence (100% vs 44%), and skill (89% vs 44%) in OUD care, but differences were not statistically significant. Self-reported frequency of providing OUD care was unchanged. During qualitative interviews (2 participants) and the focus group (3 participants), participants appreciated the training format but described confidence declining over time. Ongoing barriers to MOUD initiation included challenges with counseling patients about MOUD, discharge planning, accessing OUD care protocols and decision aides, lack of interprofessional collaboration, and time pressures.

CONCLUSION

Generalist physicians reported increases in knowledge, confidence, and skill with OUD training, but a single session was insufficient to maintain confidence and change practice. Additional training sessions emphasizing patient counseling and discharge planning should be developed and evaluated in a larger sample. Simultaneous efforts to address systemic barriers are also needed.

A Hospital-Based Intervention to Improve Access to Buprenorphine for Patients with Opioid Use Disorder

BACKGROUND

Opioid use disorder (OUD) is often under-addressed in hospitalized patients. In the absence of formal addiction consult services, volunteer physician-led models can increase access to inpatient OUD treatment. This paper describes a novel, volunteer physician-led interprofessional approach to identifying patients with OUD, initiating buprenorphine, and linking to office-based opioid treatment.

METHODS

The intervention took place from April 2018 to August 2020 at a large, urban, tertiary care center and teaching hospital in New York, NY that does not have an addiction consult service. Hospitalized patients with OUD were identified by provider-driven referrals or an automated daily patient list generated by a bioinformatics search algorithm. Eligible patients with OUD were started on buprenorphine during their hospitalization and linked to primary care-based buprenorphine treatment. Patients were followed longitudinally via chart review to assess follow-up clinic rates at >30 days, >60 days, >90 days, >6 months, >12 months, and >24 months after discharge.

RESULTS

Over a 2-year period, 178 patients were evaluated, 88 were eligible for inpatient buprenorphine, and 47 were started on buprenorphine while hospitalized. Sixty-seven patients were referred to a post-discharge visit at a primary care practice, 29 (43%) of whom attended an appointment at least 30 days after discharge. Of these, 22 (76%) returned at >60 days and 20 (69%) at 6 months. At the 1-year time point, 16 of a possible 17 patients (94%) and 15 of a possible 16 patients (94%) were still engaged in care at 2 years.

CONCLUSION

This intervention represents a proof of principle, adaptable model for identifying patients with OUD and engaging patients in primary care-based buprenorphine treatment. Limitations to consider include the sustainability of a volunteer-based initiative and that retention rates for 1 to 2 years post-discharge may be more indicative of the strengths of office-based opioid treatment itself as opposed to in-hospital engagement and the intervention.

Toward a Consensus on Strategies to Support Opioid Use Disorder Care Transitions Following Hospitalization: A Modified Delphi Process

BACKGROUND

Despite proliferation of acute-care interventions to initiate medications for opioid use disorder (MOUD), significant challenges remain to supporting care continuity following discharge. Research is needed to inform effective hospital strategies to support patient transitions to ongoing MOUD in the community.

OBJECTIVE

To inform a taxonomy of care transition strategies to support MOUD continuity from hospital to community-based settings and assess their perceived impact and feasibility among experts in the field.

DESIGN

A modified Delphi consensus process through three rounds of electronic surveys.

PARTICIPANTS

Experts in hospital-based opioid use disorder (OUD) treatment, care transitions, and hospital-based addiction treatment.

MAIN MEASURES

Delphi participants rated the impact and feasibility of 14 OUD care transition strategies derived from a review of the scientific literature on a scale from 1 to 9 over three survey rounds. Panelists were invited to suggest additional care transition strategies. Agreement level was calculated based on proportion of ratings within three points of the median.

KEY RESULTS

Forty-five of 71 invited panelists participated in the survey. Agreement on impact was strong for 12 items and moderate for 10. Agreement on feasibility was strong for 11 items, moderate for 7, and poor for 4. Strategies with highest ratings on impact and feasibility included initiation of MOUD in-hospital and provision of buprenorphine prescriptions or medications before discharge. All original 14 strategies and 8 additional strategies proposed by panelists were considered medium- or high-impact and were incorporated into a final taxonomy of 22 OUD care transition strategies.

CONCLUSIONS

Our study established expert consensus on impactful and feasible hospital strategies to support OUD care transitions from the hospital to community-based MOUD treatment, an area with little empirical research thus far. It is the hope that this taxonomy serves as a stepping-stone for future evaluations and clinical practice implementation toward improved MOUD continuity and health outcomes.

Challenges to and Solutions for Implementing Medications for Opioid Use Disorder in Community Mental Health Centers

OBJECTIVE

The purpose of this study was to identify implementation challenges to and solutions for integrating medications for opioid use disorder (MOUD) into community mental health centers (CMHCs).

METHODS

Between February and July 2024, 17 semistructured interviews were conducted with CMHC program leaders. Participants described the impetus for MOUD provision or reasons for not implementing MOUD, as well as key implementation challenges and strategies to address them.

RESULTS

Participants included staff from 10 CMHCs that provided MOUD and seven that did not. MOUD clinic staff noted that community need and leadership advocacy impelled them to offer MOUD, despite facing challenges. Reasons from non-MOUD clinic staff for not providing MOUD included a perceived lack of opioid use disorder among clients, concerns about treating people with opioid use disorder, and the need for appropriate staff and training. Implementation challenges identified by participants from MOUD clinics concerned the complexity or lack of reimbursement for MOUD-related services, lack of staff training and support, workflow misalignment, client nonadherence to MOUD, and medication costs. Several strategies were described to address these challenges, including streamlining workflows and pathways to treatment, increasing staff training and support, and leveraging telehealth.

CONCLUSIONS

Identifying implementation strategies that assist CMHCs in overcoming barriers to integrating MOUD can increase access in settings where people with co-occurring mental and opioid use disorders regularly receive care. This article provides illustrative examples of successful strategies used to address challenges faced by CMHCs and recommendations to increase MOUD uptake.

Adapting to the Fentanyl Epidemic: Rapid Qualitative Observations and Derived Clinical and Research Implications from the Emergency Department Longitudinal Integrated Care (ED-LINC) Randomized Clinical Trial

OBJECTIVE

The Emergency Department Longitudinal Integrated Care (ED-LINC) randomized clinical trial (NCT05327166) tests a Collaborative Care-informed intervention for emergency department (ED) patients with opioid use disorder. The ED-LINC intervention was developed before the current fentanyl epidemic; less than 10% of ED-LINC pilot intervention patients reported fentanyl use. To understand fentanyl's impact on the ED-LINC protocol, we utilized a systematic rapid qualitative approach to document clinical observations related to ED-LINC patients' fentanyl use and subsequent protocol modifications.

METHOD

This study utilized Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) methods to document fentanyl-related clinical observations. As participant observers, the team worked with a mixed methods consultant to analyze observations, informing adaptation to study protocol and intervention.

RESULTS

From 4/12/2022 to 2/10/2023, 86 patients enrolled in the ED-LINC trial. Forty received the ED-LINC intervention and are included in this study. Investigators identified the following themes informing adaptation to the ED-LINC intervention: 1) fentanyl-related suicide risk, 2) fentanyl-catalyzed approach to Medications for Opioid Use Disorder (MOUD), 3) fentanyl-related adaptations to measurement-based care embedded in the Collaborative Care approach, 4) fentanyl-associated survival needs, and 5) engagement challenges with fentanyl. Adaptations included incorporating overdose prevention into suicide risk assessment, nontraditional MOUD induction, and shifting to a component-driven model.

CONCLUSIONS

The landscape of clinical practice can change quickly and may require both researchers and healthcare providers to quickly pivot. Rapid assessment procedures integrated into clinical trial investigation allow for modifications and adaptations to study protocols to ensure salient and generalizable results given the rapidly evolving opioid epidemic.

Optimizing retention strategies for opioid use disorder pharmacotherapy: The retention phase of the CTN-0100 trial (RDD)

INTRODUCTION AND BACKGROUND

The three medications approved to address OUD are effective in decreasing opioid use and morbidity and mortality; however, their utility is limited by high rates of dropout from treatment. The CTN-0100 trial will develop an evidence base for strategies to improve retention on buprenorphine and extended-release naltrexone.

RESEARCH DESIGN AND METHODS

The National Drug Abuse Treatment Clinical Trials Network (CTN) study CTN-0100, "Optimizing Retention, Duration and Discontinuation Strategies for Opioid Use Disorder Pharmacotherapy" (RDD), is a multicenter, randomized, non-blinded trial enrolling more than a thousand patients from 18 community-based substance use disorder treatment programs. Participants are adult volunteers seeking to initiate medication treatment for OUD (MOUD). Individuals choose between buprenorphine or extended-release injectable naltrexone. The trial randomizes participants choosing buprenorphine, in a 3 × 2 factorial design, to a medication condition (standard-dose sublingual buprenorphine, high-dose sublingual buprenorphine, or extended-release injectable buprenorphine) and to a behavioral condition (Medical Management or Medical Management plus a digital therapeutic (smartphone) app). Individuals choosing extended-release naltrexone are randomized only to a behavioral condition. Participants receive study medication for 74 weeks and are then followed for a further 24 weeks. The primary outcome is successful retention on MOUD at 26 weeks (six months), with 50- and 74-week retention among the secondary outcomes.

DISCUSSION/CONCLUSION

Dropout from treatment is a major barrier to the effectiveness of MOUD. The CTN-0100 study will determine whether strategies such as high dose sublingual or extended-release buprenorphine, or an app-based behavioral intervention improve retention on MOUD.

CLINICALTRIALS

gov Identifier: NCT04464980.

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

STUDY OBJECTIVE(S)

To evaluate the cost-effectiveness of implementation facilitation compared with a standard educational strategy to promote emergency department (ED)-initiated buprenorphine with linkage to ongoing opioid use disorder care in the community, from a health care-sector perspective.

METHODS

A prospective cost-effectiveness analysis was conducted alongside "Project ED Health" (CTN-0069), a hybrid type 3 implementation-effectiveness study conducted at 4 academic EDs. Resources were gathered and valued according to the health care-sector perspective. Three effectiveness measures were evaluated: quality-adjusted life-years, opioid-free years, and patient engagement in community-based opioid use disorder care on the 30th day following the index ED visit. An incremental cost-effectiveness ratio was calculated for each measure of effectiveness. Likelihood of cost-effectiveness was evaluated across a wide range of "value" thresholds through cost-effectiveness acceptability curves.

RESULTS

The mean, per-person, health care-sector cost associated with ED-administered buprenorphine following implementation facilitation did not differ significantly from that of standard education ($3,239 versus $4,904), whereas the mean effectiveness for all 3 measures significantly favored the implementation facilitation strategy. Implementation facilitation has a 74% to 75% probability of being considered cost-effective from a health care-sector perspective at the recommended value range of $100,000 to $200,000 per quality-adjusted life-year. Incremental cost-effectiveness ratios estimated using secondary effectiveness measures had a 75% probability of being considered cost-effective at $25,000 per opioid-free year and $38,000 per engagement.

CONCLUSION

Implementation facilitation, relative to a standard educational strategy, has a moderate-to-high likelihood of being considered cost-effective from a health care-sector perspective, depending on decisionmakers' willingness to pay for units of effectiveness.

Initiation of buprenorphine in the emergency department or emergency out-of-hospital setting: A mixed-methods systematic review

INTRODUCTION

People who use substances increasingly access healthcare primarily through emergency medical services (EMS) and emergency departments (EDs). To meet the needs of these patients, EMS and EDs have become access points for medications for opioid use disorder (OUD), specifically buprenorphine. This systematic review aimed to quantify the efficacy of these programs, examining retention in treatment for OUD, rates of re-presentation to ED or EMS, and rates of precipitated withdrawal, as well as summarise clinician and patient perspectives on buprenorphine initiation in these settings.

METHODS

This review considered studies including patients with OUD receiving, and providers initiating, buprenorphine in an ED or EMS setting. A convergent, segregated approach to mixed-methods review was used as recommended by the Joanna Briggs Institute. A search was conducted of MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Where relevant, meta-analyses of odds ratios and proportions were conducted.

FINDINGS

In both randomised (OR 5.97, 95 %CI 2.52-14.14, 227 participants, I2 16.93 %) and observational (OR 4.28, 95 %CI 2.45-7.48, 779 participants, I2 66.97 %) research, buprenorphine in the ED or EMS setting was associated with increased odds of treatment engagement at 30 days. Rates of retention in treatment varied across measured time points, from 77 % (95 %CI 74-80 %, 763 participants, I2 0.01 %) within 24 h, to 35 % (95 %CI 29-40 %) at 12 months. A low rate of precipitated withdrawal was reported (0.00 %, 95 %CI 0.00-1.00 %, 851 participants, I2 0.00 %). Clinicians and patients were generally supportive of ED-initiated buprenorphine, while identifying the initiation buprenorphine as one component of a longitudinal care path for people with OUD. Patients valued clinicians engaging in shared decision-making, while clinicians identified the environment of the ED often made this challenging.

CONCLUSION

The initiation of buprenorphine in the ED setting is associated with higher odds of short and medium-term treatment engagement. Further research is required into EMS-initiated buprenorphine, as well as patient perspectives of ED- and EMS-initiated buprenorphine.

Implementation of medications for opioid use disorder in U.S. emergency departments: A systematic review

INTRODUCTION

Patients with opioid use disorder (OUD) experiencing withdrawal or nonfatal overdose often present to emergency departments (EDs). While professional societies endorse the initiation of evidence-based medications for OUD (MOUD) in the ED, low uptake persists. The purpose of this systematic review is to synthesize what is known about implementation of MOUD in EDs and to identify potential strategies to improve the uptake of MOUD in the ED.

METHODS

We reviewed articles that examined implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability, and cost) of MOUD in United States EDs. Peer-reviewed studies that used quantitative, qualitative, or mixed methods approaches were eligible for inclusion.

RESULTS

Twenty-seven articles met the inclusion criteria for one or more implementation outcomes. Forty-four percent (n = 11) reported on acceptability, 78 % (n = 21) reported on adoption, 26 % (n = 7) reported on appropriateness, and 15 % (n = 4) reported on feasibility. Eleven percent (n = 3) reported on fidelity, 7 % (n = 2) reported on penetration, and 7 % (n = 2) reported on sustainability. No articles reported on implementation cost. While physicians found MOUD acceptable, their comfort levels with the intervention varied. Rates of MOUD adoption were often low, but uptake may be facilitated by implementation strategies. MOUD may constrain ED time resources and exacerbate overcrowding, hindering appropriateness.

CONCLUSION

Results suggest that ED physicians and administrators have encountered barriers to the initiation of MOUD. There may be opportunities to overcome these implementation barriers using multi-component strategies consisting of educational interventions that address safety and monitoring and process interventions, such as clinical decision support systems.

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

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Statewide implementation for medications for opioid use disorder (MOUD) in urban and rural emergency departments

BACKGROUND

Medications for opioid use disorder (MOUD) programs in Emergency Departments (EDs) are feasible and effective, but uptake lags despite rising overdose deaths. NM Bridge partners with hospitals across highly rural New Mexico to guide implementation for ED-based MOUD using a Dissemination & Implementation (D&I) approach. This manuscript describes NM Bridge's outcomes in its first three years (2020-2023).

METHODS

NM Bridge offers partner hospitals a D&I intervention called implementation facilitation (IF) to guide their implementation of ED-based MOUD. The IF intervention has three mechanisms: (1) trainings, (2) a guiding blueprint (implementation plan), and (3) biweekly meetings. Each hospital receives tailored trainings, builds a team of champions who lead the work in the blueprint and are supported in biweekly meetings by the NM Bridge team. Successful implementation is defined as hospitals completing trainings, prescribing buprenorphine from the ED, and providing a warm hand-off to outpatient treatment. Primary outcomes include buprenorphine prescriptions written, clinicians trained, and peer support workers (PSW) hired.

RESULTS

From 10/2020 to 12/2023, NM Bridge recruited 34 hospitals, engaged 12, with six fully participating. In engaged hospitals (8 rural, 4 urban), 100% recognized MOUD as a vital practice, but all reported barriers of locums staffing, <25% x-waivered clinicians, and stigma. The six participating hospitals (4 rural, 2 urban) achieved 100% of IF mechanisms, variable blueprint (implementation plan) achievement, and 100% successfully implemented MOUD. This resulted in a 52.3% increase in buprenorphine prescriptions [728 patients (592 rural, 136 urban)], 144 clinicians trained, and 50% of EDs hiring a PSW.

CONCLUSIONS

Implementation facilitation of ED-based MOUD programs was successful across six diverse hospitals, in a highly rural state.

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 .

Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial

Importance

Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment.

Objective

To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement.

Design, Setting, and Participants

This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization.

Interventions

Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor.

Main Outcomes and Measures

The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation.

Results

Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18).

Conclusions

This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment.

Trial Registration

ClinicalTrials.gov Identifier: NCT03611335.

Availability and Opportunities for Expansion of Buprenorphine for the Treatment of Opioid Use Disorder

There is an urgent need to expand access to treatment for persons with opioid use disorder (OUD). As neurologists may frequently encounter patients with chronic pain who have developed OUD, they are in a position to serve as advocates for treatment. Buprenorphine is the most scalable medication for OUD in the United States, yet expansion has plateaued in recent years despite growing treatment needs. Reluctance of providers to establish treatment with new patients, challenges with rural expansion, stigma related to buprenorphine-based care, and pharmacy pressures that incentivize low dispensing and inventories may have stalled expansion. This review introduces these challenges before outlining actionable and evidenced-based strategies that warrant investigation, including methods to improve patient access to care (remotely delivered care, mobile delivery programs, Bridge programs) and provider retention and confidence in prescribing (expert consults, Extension for Community Healthcare Outcomes, a telementoring model, hub-and-spoke services), as well as novel innovations (virtual reality, artificial intelligence, wearable technologies). Overall, fortifying existing delivery systems while developing new transformative models may be necessary to achieve more optimal levels of buprenorphine treatment expansion.

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.

A qualitative assessment of emergency physicians' experiences with robust emergency department buprenorphine bridge programs

OBJECTIVES

Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD.

METHODS

Semistructured interviews were conducted with EPs from four geographically diverse academic hospitals with established EDBPs. Interviews were recorded and transcribed, and emergent themes were identified using codebook thematic analysis. Analysis credibility and transparency were confirmed with peer debriefing.

RESULTS

Twenty-two interviews were conducted across the four sites. Three key themes were constructed during the analyses: (1) provided EPs agency; (2) transformed EPs' emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EPs' professional quality of life.

CONCLUSIONS

Participants in this study reported several common themes related to participation in their hospital's BP. Overall our results suggest that physicians who participate in EDBPs may feel a renewed sense of fulfillment and purpose in their personal and professional lives. These positive changes may lead to increased job satisfaction in hospitals that have successfully launched EDBP.

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.

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.

Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations

BACKGROUND

Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care.

METHODS

This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber).

DISCUSSION

This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes.

TRIAL REGISTRATION

The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www.

CLINICALTRIALS

gov/study/NCT05310786?id=NCT05310786&rank=1.

Screening for problematic opioid use in the emergency department: Comparison of two screening measures

Study objective

Earlier intervention for opioid use disorder (OUD) may reduce long-term health implications. Emergency departments (EDs) in the United States treat millions with OUD annually who may not seek care elsewhere. Our objectives were (1) to compare two screening measures for OUD characterization in the ED and (2) to determine the proportion of ED patients screening positive for OUD and those who endorse other substance use to guide future screening programs.

Methods

A cross-sectional study of randomly selected adult patients presenting to three Midwestern US EDs were enrolled, with duplicate patients excluded. Surveys were administered via research assistant and documented on tablet devices. Demographics were self-reported, and OUD positivity was assessed by the DSM 5 checklist and the WHO ASSIST 3.1. The primary outcome was the concordance between two screening measures for OUD. Our secondary outcome was the proportion of ED patients meeting OUD criteria and endorsed co-occurring substance use disorder (SUD) criteria.

Results

We enrolled 1305 participants; median age of participants was 46 years (range 18-84), with 639 (49.0%) Non-Hispanic, White, and 693 (53.1%) female. Current OUD positivity was identified in 17% (222 out of 1305) of the participants via either DSM-5 (two or more criteria) or ASSIST (score of 4 or greater). We found moderate agreement between the measures (kappa = 0.56; Phi coefficient = 0.57). Of individuals screening positive for OUD, 182 (82%) endorsed criteria for co-occurring SUD.

Conclusions

OUD is remarkably prevalent in ED populations, with one in six ED patients screening positive. We found a high prevalence of persons identified with OUD and co-occurring SUD, with moderate agreement between measures. Developing and implementing clinically feasible OUD screening in the ED is essential to enable intervention.

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.

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.

National Institute on Drug Abuse Clinical Trials Network Meeting Report: Advancing Emergency Department Initiation of Buprenorphine for Opioid Use Disorder

Opioid use disorder and opioid overdose deaths are a major public health crisis, yet highly effective evidence-based treatments are available that reduce morbidity and mortality. One such treatment, buprenorphine, can be initiated in the emergency department (ED). Despite evidence of efficacy and effectiveness for ED-initiated buprenorphine, universal uptake remains elusive. On November 15 and 16, 2021, the National Institute on Drug Abuse Clinical Trials Network convened a meeting of partners, experts, and federal officers to identify research priorities and knowledge gaps for ED-initiated buprenorphine. Meeting participants identified research and knowledge gaps in 8 categories, including ED staff and peer-based interventions; out-of-hospital buprenorphine initiation; buprenorphine dosing and formulations; linkage to care; strategies for scaling ED-initiated buprenorphine; the effect of ancillary technology-based interventions; quality measures; and economic considerations. Additional research and implementation strategies are needed to enhance adoption into standard emergency care and improve patient outcomes.

Perspectives of Clinicians and Staff at Community-Based Opioid Use Disorder Treatment Settings on Linkages With Emergency Department-Initiated Buprenorphine Programs

Importance

An increasing number of emergency departments (EDs) are initiating buprenorphine for opioid use disorder (OUD) and linking patients to ongoing community-based treatment, yet community-based clinician and staff perspectives regarding this practice have not been characterized.

Objective

To explore perspectives and experiences regarding ED-initiated buprenorphine among community-based clinicians and staff in geographically distinct regions.

Design, Setting, and Participants

This qualitative study reports findings from Project ED Health, a hybrid type 3 effectiveness-implementation study designed to evaluate the impact of implementation facilitation on ED-initiated buprenorphine with referral to ongoing medication treatment. Clinicians and staff from community-based treatment programs were identified by urban academic EDs as potential referral sites for ongoing OUD treatment in 4 cities across the US in a formative evaluation as having the capability to continue medication treatment. Focus groups were held from April 1, 2018, to January 11, 2019, to examine community OUD treatment clinician and staff perspectives on accepting patients who have received ED-initiated buprenorphine. Data were analyzed from August 2020 to August 2022.

Main Outcomes and Measures

Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework, focusing on domains including evidence, context, and facilitation.

Results

A total of 103 individuals (mean [SD] age, 45.3 [12.0] years; 76 female and 64 White) participated in 14 focus groups (groups ranged from 3-22 participants). Participants shared negative attitudes toward buprenorphine and variable attitudes toward ED-initiated buprenorphine. Prominent barriers included the community site treatment capacity and structure as well as payment and regulatory barriers. Perceived factors that could facilitate this model included additional substance use disorder training for ED staff, referrals and communication, greater inclusion of peer navigators, and addressing sociostructural marginalization that patients faced.

Conclusions and Relevance

In this study of community-based clinicians and staff positioned to deliver OUD treatment, participants reported many barriers to successful linkages for patients who received ED-initiated buprenorphine. Strategies to improve these linkages included educating communities and programs, modeling low-barrier philosophies, and using additional staff trained in addiction as resources to improve transitions from EDs to community partners.