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LeSaint KT, Kendric KJ, Logan AA. Successful administration of extended-release buprenorphine in the emergency department. Am J Emerg Med 2024:S0735-6757(24)00368-1. [PMID: 39089938 DOI: 10.1016/j.ajem.2024.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 07/22/2024] [Indexed: 08/04/2024] Open
Abstract
INTRODUCTION The ongoing opioid epidemic in the United States has resulted in a substantial increase in overdose deaths and related morbidity and mortality. Given that emergency departments (ED) frequently serve as the initial point of contact for individuals experiencing opioid overdose or seeking treatment for opioid use disorder (OUD), ED clinicians have a pivotal role to play in providing prompt and effective treatment for OUD. While ED clinicians routinely administer sublingual and other transmucosal formulations of buprenorphine, extended-release buprenorphine (BUP-XR) remains underutilized in the ED. CASE REPORT We present a case involving the successful administration of BUP-XR in the ED to a patient experiencing spontaneous opioid withdrawal. The patient tolerated test dosing of sublingual buprenorphine (BUP-SL) and subsequently received BUP-XR in the ED. Following this intervention, the patient was referred to the hospital-affiliated substance use disorder outpatient clinic, where he has since demonstrated successful follow-up and retention in treatment. CONCLUSION Our report adds to the existing limited literature on the administration of BUP-XR in the ED and highlights the need for more comprehensive clinician teaching and guidance, as well as the establishment of in-hospital protocols for BUP-XR. Despite these challenges, our case indicates that initiating BUP-XR could be a viable and effective option for ED patients with OUD.
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Affiliation(s)
- Kathy T LeSaint
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA; California Poison Control System, San Francisco Division, San Francisco, CA, USA
| | - Kayla J Kendric
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA; California Poison Control System, San Francisco Division, San Francisco, CA, USA.
| | - Alexander A Logan
- Division of Hospital and Addiction Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
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Heil JM, Lassiter JM, Salzman MS, Herring A, Hoppe J, Lynch M, Weiner SG, Roberts B, Haroz R. A qualitative assessment of emergency physicians' experiences with robust emergency department buprenorphine bridge programs. Acad Emerg Med 2024; 31:576-583. [PMID: 38357749 DOI: 10.1111/acem.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 02/16/2024]
Abstract
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.
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Affiliation(s)
- Jessica Marie Heil
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
| | | | - Matthew S Salzman
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
| | - Andrew Herring
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, University of California, San Francisco, California, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Colorado, Aurora, USA
| | - Michael Lynch
- University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott G Weiner
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian Roberts
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
| | - Rachel Haroz
- Center for Healing, Division of Addiction Medicine, Cooper University Health Care, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Cooper University Health Care, Camden, New Jersey, USA
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey, USA
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Justen M, Edelman EJ, Chawarski M, Coupet E, Cowan E, Lyons M, Owens P, Martel S, Richardson L, Rothman R, Whiteside L, O'Connor PG, Zahn E, D'Onofrio G, Fiellin DA, Hawk KF. Perspectives on and experiences of emergency department-initiated buprenorphine among clinical pharmacists: A multi-site qualitative study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209058. [PMID: 37149149 DOI: 10.1016/j.josat.2023.209058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/05/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
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.
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Affiliation(s)
- Marissa Justen
- Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, United States of America.
| | - E Jennifer Edelman
- Yale School of Medicine, Department of Internal Medicine, Edward S. Harkness, Building A, 4th floor 367 Cedar Street, New Haven, CT 06510, United States of America
| | - Marek Chawarski
- Yale School of Medicine, Department of Psychiatry, 300 George St #901, New Haven, CT 06511, United States of America
| | - Edouard Coupet
- Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
| | - Ethan Cowan
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States of America
| | - Michael Lyons
- University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, United States of America
| | - Patricia Owens
- Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
| | - Shara Martel
- Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
| | - Lynne Richardson
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029, United States of America
| | - Richard Rothman
- John Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, United States of America
| | - Lauren Whiteside
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America
| | - Patrick G O'Connor
- Yale School of Medicine, Department of Internal Medicine, Edward S. Harkness, Building A, 4th floor 367 Cedar Street, New Haven, CT 06510, United States of America
| | - Evan Zahn
- Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, United States of America
| | - Gail D'Onofrio
- Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
| | - David A Fiellin
- Yale School of Medicine, Department of Internal Medicine, Edward S. Harkness, Building A, 4th floor 367 Cedar Street, New Haven, CT 06510, United States of America; Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
| | - Kathryn F Hawk
- Yale School of Medicine, Department of Emergency Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519, United States of America
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McCormack RP, Rotrosen J, Gauthier P, D'Onofrio G, Fiellin DA, Marsch LA, Novo P, Liu D, Edelman EJ, Farkas S, Matthews AG, Mulatya C, Salazar D, Wolff J, Knight R, Goodman W, Williams J, Hawk K. Implementing Programs to Initiate Buprenorphine for Opioid Use Disorder Treatment in High-Need, Low-Resource Emergency Departments: A Nonrandomized Controlled Trial. Ann Emerg Med 2023; 82:272-287. [PMID: 37140493 PMCID: PMC10524047 DOI: 10.1016/j.annemergmed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 05/05/2023]
Abstract
STUDY OBJECTIVE We hypothesized that implementation facilitation would enable us to rapidly and effectively implement emergency department (ED)-initiated buprenorphine programs in rural and urban settings with high-need, limited resources and dissimilar staffing structures. METHODS This multicenter implementation study employed implementation facilitation using a participatory action research approach to develop, introduce, and refine site-specific clinical protocols for ED-initiated buprenorphine and referral in 3 EDs not previously initiating buprenorphine. We assessed feasibility, acceptability, and effectiveness by triangulating mixed-methods formative evaluation data (focus groups/interviews and pre/post surveys involving staff, patients, and stakeholders), patients' medical records, and 30-day outcomes from a purposive sample of 40 buprenorphine-receiving patient-participants who met research eligibility criteria (English-speaking, medically stable, locator information, nonprisoners). We estimated the primary implementation outcome (proportion receiving ED-initiated buprenorphine among candidates) and the main secondary outcome (30-day treatment engagement) using Bayesian methods. RESULTS Within 3 months of initiating the implementation facilitation activities, each site implemented buprenorphine programs. During the 6-month programmatic evaluation, there were 134 ED-buprenorphine candidates among 2,522 encounters involving opioid use. A total of 52 (41.6%) practitioners initiated buprenorphine administration to 112 (85.1%; 95% confidence interval [CI] 79.7% to 90.4%) unique patients. Among 40 enrolled patient-participants, 49.0% (35.6% to 62.5%) were engaged in addiction treatment 30 days later (confirmed); 26 (68.4%) reported attending one or more treatment visits; there was a 4-fold decrease in self-reported overdose events (odds ratio [OR] 4.03; 95% CI 1.27 to 12.75). The ED clinician readiness increased by a median of 5.02 (95% CI: 3.56 to 6.47) from 1.92/10 to 6.95/10 (n(pre)=80, n(post)=83). CONCLUSIONS The implementation facilitation enabled us to effectively implement ED-based buprenorphine programs across heterogeneous ED settings rapidly, which was associated with promising implementation and exploratory patient-level outcomes.
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Affiliation(s)
| | - John Rotrosen
- New York University Grossman School of Medicine, New York, NY
| | | | - Gail D'Onofrio
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - David A Fiellin
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Lisa A Marsch
- Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Patricia Novo
- New York University Grossman School of Medicine, New York, NY
| | - David Liu
- National Institute on Drug Abuse, Rockville, MD
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Medicine, Department of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
| | - Sarah Farkas
- New York University Grossman School of Medicine, New York, NY
| | | | | | | | | | | | | | | | - Kathryn Hawk
- Yale School of Medicine, Department of Emergency Medicine, New Haven, CT; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT; Yale School of Public Health, New Haven, CT
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Whiteside LK, D'Onofrio G, Fiellin DA, Edelman EJ, Richardson L, O'Connor P, Rothman RE, Cowan E, Lyons MS, Fockele CE, Saheed M, Freiermuth C, Punches BE, Guo C, Martel S, Owens PH, Coupet E, Hawk KF. Models for Implementing Emergency Department-Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers. Ann Emerg Med 2022; 80:410-419. [PMID: 35752520 PMCID: PMC9588652 DOI: 10.1016/j.annemergmed.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 12/24/2022]
Abstract
There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.
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Affiliation(s)
- Lauren K Whiteside
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA.
| | - Gail D'Onofrio
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - David A Fiellin
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - E Jennifer Edelman
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrick O'Connor
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael S Lyons
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Callan E Fockele
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Freiermuth
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brittany E Punches
- Department of Emergency Medicine, Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Clara Guo
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Shara Martel
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Patricia H Owens
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Edouard Coupet
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kathryn F Hawk
- Department of Emergency Medicine, Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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A Neuropharmacological Model to Explain Buprenorphine Induction Challenges. Ann Emerg Med 2022; 80:509-524. [DOI: 10.1016/j.annemergmed.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022]
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Kelly TD, Hawk KF, Samuels EA, Strayer RJ, Hoppe JA. Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions. West J Emerg Med 2022; 23:461-467. [PMID: 35980414 PMCID: PMC9391022 DOI: 10.5811/westjem.2022.2.52978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.
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Affiliation(s)
- Timothy D. Kelly
- Indiana University Emergency Medicine Residency, Indianapolis, Indiana
| | - Kathryn F. Hawk
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Elizabeth A. Samuels
- Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Reuben J. Strayer
- Maimonides Medical Center, Department of Emergency Medicine, Brooklyn, New York
| | - Jason A. Hoppe
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Keshwani S, Maguire M, Goodin A, Lo-Ciganic WH, Wilson DL, Hincapie-Castillo JM. Buprenorphine Use Trends Following Removal of Prior Authorization Policies for the Treatment of Opioid Use Disorder in 2 State Medicaid Programs. JAMA HEALTH FORUM 2022; 3:e221757. [PMID: 35977240 PMCID: PMC9233239 DOI: 10.1001/jamahealthforum.2022.1757] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 04/28/2022] [Indexed: 01/04/2023] Open
Abstract
Question What are the outcomes of removing prior authorizations (PAs) on buprenorphine for opioid use disorder (OUD) in Medicaid programs? Findings In this cross-sectional study of Medicaid State Drug Utilization Data from 2 states, buprenorphine prescribing for OUD in the state Medicaid program of Illinois increased after removing PA requirements, whereas a similar increase was not observed in the state Medicaid program of California. Meaning Policies removing PA requirements for buprenorphine prescribing for treatment of OUD may improve access to OUD treatment in Medicaid enrollees. Importance State Medicaid programs have implemented initiatives to expand treatment coverage for opioid use disorder (OUD); however, some Medicaid programs still require prior authorizations (PAs) for filling buprenorphine prescriptions. Objective To evaluate the changes in buprenorphine use for OUD among Medicaid enrollees in states that completely removed buprenorphine PA requirements. Design, Setting, and Participants This retrospective cross-sectional study analyzed the immediate and trend changes on buprenorphine use during 2013 to 2020 associated with removal of PA requirements using a controlled interrupted time series analysis to account for autocorrelation. Data were collected from Medicaid State Drug Utilization Data for 2 states (California and Illinois) that completely removed a buprenorphine PA during the study period, and buprenorphine prescriptions for OUD treatment were identified among Medicaid enrollees. Main Outcomes and Measures Quarterly total number of buprenorphine prescriptions for each state was calculated, and stratification analyses were conducted by dosage form (films and tablets). Results Among the 2 state Medicaid programs (California and Illinois) that removed buprenorphine PAs, there was a total of 702 643 and 415 115 eligible buprenorphine prescription claims, respectively. After removing PA requirements for buprenorphine, there was an immediate increase that was not statistically significant (rate ratio [RR], 1.11; 95% CI, 0.76-1.61) in the number of all buprenorphine prescriptions in California and a statistically significant increase (RR, 6.99; 95% CI, 4.67-10.47) in the number of all buprenorphine prescriptions in Illinois relative to the change in the control states (Alabama, Florida, Idaho, Kansas, Mississippi, Nevada, South Dakota, and Wyoming). Additionally, there was a statistically significant decreasing trend in the number of all buprenorphine prescriptions in California (RR, 0.88; 95% CI, 0.82-0.94) and a statistically significant increasing trend in Illinois (RR, 1.11; 95% CI, 1.05-1.19) relative to the trend in control states. Conclusions and Relevance In this cross-sectional study, removal of buprenorphine PA requirements was associated with a statistically significant increase in the number of buprenorphine prescription fills among Medicaid populations in 1 of the 2 included states.
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Affiliation(s)
- Shailina Keshwani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Michael Maguire
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
| | - Amie Goodin
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Juan M. Hincapie-Castillo
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
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Yu MJ, Hawk K. Resident attitudes, experiences, and preferences on initiating buprenorphine in the emergency department: A national survey. AEM EDUCATION AND TRAINING 2022; 6:e10779. [PMID: 35784380 PMCID: PMC9242423 DOI: 10.1002/aet2.10779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The objective was to describe emergency medicine (EM) resident attitudes, preferences, and experiences around the knowledge and skills around the evidence-based treatment of opioid use disorder (OUD) in the emergency department (ED). METHODS We created an online survey that was distributed by the Emergency Medicine Residents' Association research committee listserv to approximately 6600 resident physicians at all levels of EM residency training. Data were collected between June 2020 and October 2020. This 12-question voluntary, anonymous survey included questions exploring EM resident preferences and experiences around the education and exposure to the evidence-based management of patients with OUD in the ED setting. Descriptive statistics were used. RESULTS A total of 288 of 6600 invited EM residents (response rate 4.4%) from 127 different EM residency programs across 38 states in the United States, District of Columbia, and Puerto Rico completed the survey. Most respondents (165/288; 57.3%) reported that it was "very important" for emergency physicians to have training to initiate buprenorphine treatment for patients with OUD. Just under half (140/288; 48.6%) reported they have or will receive X-waiver training during residency and 46.9% (135/288) reported experience prescribing buprenorphine in the ED. The estimated proportions of EM faculty at responding residents' primary teaching hospital with an X-waiver was "most or all" (48/285; 16.8%), "about half" (23/285; 8.1%), "a handful" (79/285; 27.7%), "one or two" (33/285; 11.6%), "none" (19/285; 6.7%), or "not sure" (83/285; 29.1%). CONCLUSION Survey results suggest that resident emergency physicians perceive the evidence-based management of OUD to be relevant to EM residency training and are interested in receiving training on initiating medications for OUD treatment in the ED. Opportunities to improve resident education and clinical use of buprenorphine during ED residency training were identified.
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Affiliation(s)
- Megan J. Yu
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kathryn Hawk
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
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10
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Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med 2022; 58:22-26. [DOI: 10.1016/j.ajem.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 01/19/2023] Open
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Kelsch JR, Bailey AM, Baum RA, Metts EL, Weant KA. Guidance for emergency medicine pharmacists to improve care for people with opioid use disorder. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jordan R. Kelsch
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Abby M. Bailey
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Regan A. Baum
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Elise L. Metts
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Kyle A. Weant
- Department of Clinical Pharmacy and Outcome Sciences University of South Carolina College of Pharmacy Columbia South Carolina USA
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Identifying barriers to emergency department-initiated buprenorphine: A spatial analysis of treatment facility access in Michigan. Am J Emerg Med 2021; 51:393-396. [PMID: 34826787 DOI: 10.1016/j.ajem.2021.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/06/2021] [Accepted: 11/07/2021] [Indexed: 11/23/2022] Open
Abstract
STUDY OBJECTIVES Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access. METHODS Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers. RESULTS Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress. CONCLUSION Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.
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Varney SM, Wiegand TJ, Wax PM, Brent J. Descriptive Analysis of Inpatient and Outpatient Cohorts Seeking Treatment After Prescription Opioid Misuse and Medical Toxicology Evaluation. J Med Toxicol 2021; 17:378-385. [PMID: 34402039 DOI: 10.1007/s13181-021-00850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Medical toxicology expertise has expanded into the addiction medicine realm including outpatient medication for opioid use disorder (MOUD) and addiction treatment. Concomitantly, the emergency department (ED) and hospital are increasingly seen as important sites for the screening, prevention, and treatment of patients with substance use disorders and addiction. This analysis seeks to characterize patients seen by medical toxicologists for opioid use and opioid use disorder (OUD) in the ED and inpatient consultation setting (inpatient) versus in the OUD clinic (outpatient) setting. METHODS We searched the American College of Medical Toxicology's Toxicology Investigators Consortium Case Registry, a prospective, de-identified, national dataset that includes patients receiving medical toxicology consultation following prescription opioid misuse. The dataset also includes patients seen in outpatient MOUD clinics during the same period between June 2013 and November 2015. Intentional self-harm patients were excluded. We analyzed medical history, drug use patterns, and other factors with odds ratios and confidence intervals. RESULTS Of 110 patients identified, 60 (54.5%) were inpatients and 50 (45.5%) outpatients. Mean age (39 years), gender (68% male), and race breakdown (60% white/non-Hispanic) were similar. The outpatient group was more likely to have Medicare/Medicaid coverage (p<0.0001). By history, the outpatient group was more likely to have past alcohol misuse, intravenous drug use, prescription drug misuse, and prescription opioid misuse. Most inpatient group members sought a recreational high compared to avoiding withdrawal or treating dependence in the outpatient group. CONCLUSION Patients treated in the outpatient compared to inpatient setting were more likely to report adverse sequelae from their drug use including long-term drug use, depression, previous rehabilitation attempts, and seeking to avoid withdrawal.
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Affiliation(s)
- Shawn M Varney
- Department of Emergency Medicine, University of Texas Health - San Antonio, 7703 Floyd Curl Dr, San Antonio, TX, 78229, USA.
| | - Timothy J Wiegand
- University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Paul M Wax
- Division of Toxicology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine and Colorado School of Public Health, 13001 E 17th Pl, Aurora, CO, 80045, USA
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Herring AA, Vosooghi AA, Luftig J, Anderson ES, Zhao X, Dziura J, Hawk KF, McCormack RP, Saxon A, D’Onofrio G. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA Netw Open 2021; 4:e2117128. [PMID: 34264326 PMCID: PMC8283555 DOI: 10.1001/jamanetworkopen.2021.17128] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/12/2021] [Indexed: 12/26/2022] Open
Abstract
Importance Emergency departments (EDs) sporadically use a high-dose buprenorphine induction strategy for the treatment of opioid use disorder (OUD) in response to the increasing potency of the illicit opioid drug supply and commonly encountered delays in access to follow-up care. Objective To examine the safety and tolerability of high-dose (>12 mg) buprenorphine induction for patients with OUD presenting to an ED. Design, Setting, and Participants In this case series of ED encounters, data were manually abstracted from electronic health records for all ED patients with OUD treated with buprenorphine at a single, urban, safety-net hospital in Oakland, California, for the calendar year 2018. Data analysis was performed from April 2020 to March 2021. Interventions ED physicians and advanced practice practitioners were trained on a high-dose sublingual buprenorphine induction protocol, which was then clinically implemented. Main Outcomes and Measures Vital signs; use of supplemental oxygen; the presence of precipitated withdrawal, sedation, and respiratory depression; adverse events; length of stay; and hospitalization during and 24 hours after the ED visit were reported according to total sublingual buprenorphine dose (range, 2 to >28 mg). Results Among a total of 391 unique patients (median [interquartile range] age, 36 [29-48] years), representing 579 encounters, 267 (68.3%) were male and 170 were (43.5%) Black. Homelessness (88 patients [22.5%]) and psychiatric disorders (161 patients [41.2%]) were common. A high dose of sublingual buprenorphine (>12 mg) was administered by 54 unique clinicians during 366 (63.2%) encounters, including 138 doses (23.8%) greater than or equal to 28 mg. No cases of respiratory depression or sedation were reported. All 5 (0.8%) cases of precipitated withdrawal had no association with dose; 4 cases occurred after doses of 8 mg of buprenorphine. Three serious adverse events unrelated to buprenorphine were identified. Nausea or vomiting was rare (2%-6% of cases). The median (interquartile range) length of stay was 2.4 (1.6-3.75) hours. Conclusions and Relevance These findings suggest that high-dose buprenorphine induction, adopted by multiple clinicians in a single-site urban ED, was safe and well tolerated in patients with untreated OUD. Further prospective investigations conducted in multiple sites would enhance these findings.
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Affiliation(s)
- Andrew A. Herring
- Department of Emergency Medicine, Highland Hospital—Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Aidan A. Vosooghi
- Department of Emergency Medicine, Highland Hospital—Alameda Health System, Oakland, California
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Joshua Luftig
- Department of Emergency Medicine, Highland Hospital—Alameda Health System, Oakland, California
| | - Erik S. Anderson
- Department of Emergency Medicine, Highland Hospital—Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco, San Francisco
| | - Xiwen Zhao
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut
| | - James Dziura
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ryan P. McCormack
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Andrew Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology Yale School of Public Health, New Haven, Connecticut
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New and Emerging Opioid Overdose Risk Factors. CURRENT ADDICTION REPORTS 2021; 8:319-329. [PMID: 33907663 PMCID: PMC8061156 DOI: 10.1007/s40429-021-00368-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
Purpose of Review The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis. Recent Findings Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose. Summary The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.
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Sharp decline in hospital and emergency department initiated buprenorphine for opioid use disorder during COVID-19 state of emergency in California. J Subst Abuse Treat 2020; 123:108260. [PMID: 33612194 PMCID: PMC7832157 DOI: 10.1016/j.jsat.2020.108260] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/06/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
Abstract
The California Bridge Program supports expansion of medications for opioid use disorder (MOUD) in emergency departments (EDs) and hospital inpatient units across the state. Here, we describe the change in activity before and after the coronavirus disease 2019 (COVID-19) California statewide shutdown. Of the 70 participating hospitals regionally distributed across California, 52 report MOUD-related activity monthly. We analyzed data on outcomes of OUD care and treatment: identification of OUD, acceptance of referral, receipt of buprenorphine prescription, administration of buprenorphine, and follow-up linkage to outpatient OUD treatment, from May 2019 to April 2020. In estimating the expected number of patients who met each outcome in April 2020, we found decreases in the expected to observed number of patients across all outcomes (all p-values<0.002): 37% (from 1053 to 667) decrease in the number of patients identified with OUD, 34% (from 632 to 420) decrease in the number of patients who accepted a referral, 48% (from 521 to 272) decrease in the number of patients who were prescribed buprenorphine, 53% (from 501 to 234) decrease in the number of patients who were administered buprenorphine, and 33% (from 416 to 277) decrease in the number of patients who attended at least one follow-up visit for addiction treatment. The COVID-19 California statewide shutdown was associated with an abrupt and large decrease in the progress toward expanded access to OUD treatment.
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Beauchamp GA, Laubach LT, Esposito SB, Yazdanyar A, Roth P, Lauber P, Allen J, Boateng N, Shaak S, Burmeister DB. Implementation of a Medication for Addiction Treatment (MAT) and Linkage Program by Leveraging Community Partnerships and Medical Toxicology Expertise. J Med Toxicol 2020; 17:176-184. [PMID: 33146875 DOI: 10.1007/s13181-020-00813-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Implementing a hospital medication for addiction treatment (MAT) and a linkage program can improve care for patients with substance use disorder (SUD); however, lack of hospital funding and brick and mortar SUD resources are potential barriers to feasibility. METHODS This study assesses the feasibility of implementation of a SUD linkage program. Components of the program include a county-funded hospital opioid support team (HOST), a hospital-employed addiction recovery specialist (ARS), and a medical toxicology MAT induction service and maintenance program. Data for linkage by HOST, ARS, and MAT program were tracked from July 2018 to December 2019. RESULTS From July 2018 through December 2019, 1834 patients were linked to treatment: 1536 by HOST and 298 by the ARS. The most common disposition categories for patients linked by HOST were 16.73% to medically monitored detoxification, 9.38% to intensive outpatient, and 8.59% to short-term residential treatment. Among patients linked by the ARS, 65.66% were linked to outpatient treatment and 9.43% were linked directly to inpatient treatment. A total of 223 patients managed by the ARS were started on MAT by medical toxicology and linked to outpatient MAT clinic: 72.68% on buprenorphine/naloxone, 24.59% on naltrexone, 1.09% buprenorphine, and 0.55% acamprosate. CONCLUSION Implementing a MAT and linkage program in the ED and hospital setting was feasible. Leveraging medical toxicology expertise as well as community and funding partnerships was crucial to successful implementation.
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Affiliation(s)
- Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA. .,Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.
| | - Lexis T Laubach
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Samantha B Esposito
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Paige Roth
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Priyanka Lauber
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Jamie Allen
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Nathan Boateng
- Air Products Center for Connected Care and Innovation, Lehigh Valley Health Network, Allentown, PA, USA
| | - Samantha Shaak
- Department of Community Health, Lehigh Valley Health Network, Allentown, PA, USA
| | - David B Burmeister
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
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Salter H, Hutton J, Cantwell K, Dietze P, Higgs P, Straub A, Zordan R, Lloyd‐Jones M. Review article: Rapid review of the emergencydepartment‐initiatedbuprenorphine for opioid use disorder. Emerg Med Australas 2020; 32:924-934. [DOI: 10.1111/1742-6723.13654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Helen Salter
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Jennie Hutton
- Emergency Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Kate Cantwell
- Ambulance Victoria Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
| | - Paul Dietze
- Behaviours and Health Risks Program Burnet Institute Melbourne Victoria Australia
- National Drug Research Institute Curtin University Perth Western Australia Australia
| | - Peter Higgs
- Department of Public Health La Trobe University Melbourne Victoria Australia
| | - Adam Straub
- Department of Addiction Medicine St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Rachel Zordan
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- Department of Education and Learning St Vincent's Hospital Melbourne Melbourne Victoria Australia
| | - Martyn Lloyd‐Jones
- Department of Addiction Medicine St Vincent's Hospital Melbourne Melbourne Victoria Australia
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Zuckerman M, Kelly T, Heard K, Zosel A, Marlin M, Hoppe J. Physician attitudes on buprenorphine induction in the emergency department: results from a multistate survey. Clin Toxicol (Phila) 2020; 59:279-285. [PMID: 32870039 DOI: 10.1080/15563650.2020.1805461] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE Emergency Departments (ED) are rapidly becoming an important location for initiation of buprenorphine (EDBUP) for the treatment of opioid use disorder (OUD). Previous investigations of emergency medicine physicians' perceived barriers and attitudes toward EDBUP exclusively sampled from urban, academic-affiliated physicians. We administered a multistate survey to an institutionally and geographically diverse collection of emergency medicine physicians to better understand the professional opinions of EDBUP implementation across a variety of practice settings. METHODS This cross-sectional survey study used an online survey instrument to convenience sample emergency medicine physicians. In order to sample from various practice environments, participants were identified from (1) statewide ACEP chapters and (2) Facebook groups exclusive to emergency medicine physicians. The survey explored physicians' attitudes of EDBUP adoption and the perceived barriers to doing so. RESULTS 162 emergency medicine physicians completed the survey. 76% of respondents agreed that emergency medicine physicians should offer EDBUP in the treatment of OUD. When stratified by practice setting and X-waiver status, 96% of X-waivered physicians, 73% of academic physicians, 49% of non-academic physicians, and 34% of non-X-waivered physicians felt comfortable initiating EDBUP. Lack of access to outpatient MOUD referral was the most frequently cited barrier to EDBUP across all practice settings. CONCLUSIONS An institutionally and geographically diverse group of emergency medicine physicians endorsed substantial support for EDBUP. Emergency medicine physicians practicing in different clinical environments endorsed similar barriers to EDBUP implementation.
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Affiliation(s)
- Matthew Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Timothy Kelly
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Zosel
- Department of Emergency Medicine, Section of Medical Toxicology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Marlin
- Department of Emergency Medicine, Medical Toxicology Services, University of Mississippi Medical Center, MI, USA
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Hawk KF, D’Onofrio G, Chawarski MC, O’Connor PG, Cowan E, Lyons MS, Richardson L, Rothman RE, Whiteside LK, Owens PH, Martel SH, Coupet E, Pantalon M, Curry L, Fiellin DA, Edelman EJ. Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine. JAMA Netw Open 2020; 3:e204561. [PMID: 32391893 PMCID: PMC7215257 DOI: 10.1001/jamanetworkopen.2020.4561] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
IMPORTANCE Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. OBJECTIVE To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. DESIGN, SETTING, AND PARTICIPANTS Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. MAIN OUTCOMES AND MEASURES Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. RESULTS Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. CONCLUSIONS AND RELEVANCE Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.
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Affiliation(s)
- Kathryn F. Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marek C. Chawarski
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Patrick G. O’Connor
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Patricia H. Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shara H. Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Michael Pantalon
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Leslie Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - David A. Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Englander H, Priest KC, Snyder H, Martin M, Calcaterra S, Gregg J. A Call to Action: Hospitalists' Role in Addressing Substance Use Disorder. J Hosp Med 2020; 15:184-187. [PMID: 31634100 PMCID: PMC7064302 DOI: 10.12788/jhm.3311] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Honora Englander
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kelsey C Priest
- School of Medicine, MD/PhD Program, Oregon Health & Science University, Portland, Oregon
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon
| | - Hannah Snyder
- Department of Family Medicine, University of California, San Francisco, California
| | - Marlene Martin
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital and the Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Susan Calcaterra
- University of Colorado, Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, Denver, Colorado
| | - Jessica Gregg
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
- Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
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Chenworth M, Perrone J, Love JS, Greller HA, Sarker A, Chai PR. Buprenorphine Initiation in the Emergency Department: a Thematic Content Analysis of a #firesidetox Tweetchat. J Med Toxicol 2020; 16:262-268. [PMID: 31898154 DOI: 10.1007/s13181-019-00754-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The height of the opioid epidemic in the USA has led to an increasing call for access to medication assisted treatment for opioid use disorder, including buprenorphine initiation from the emergency department (ED). However, only a small percentage of emergency physicians feel prepared or have the necessary training to prescribe buprenorphine. Twitter has increasingly been used as a tool for medical education, and there is growing interest in using this forum to actively engage medical providers and the public. This study examined the views regarding ED initiation of buprenorphine treatment among contributors to the quarterly American College of Medical Toxicology (ACMT) tweetchat, #firesidetox, and the demographics of the participants. METHODS A mixed methods descriptive study was conducted to analyze individual responses and self-identified demographics among Twitter users participating in the #firesidetox tweetchat regarding the ACMT position statement about ED initiation of buprenorphine treatment. RESULTS This tweetchat included 86 participants, the majority of whom were clinicians in the USA. Physicians accounted for 46% of participants primarily emergency medicine physician toxicologists and authored 75% of the tweets. It consisted of 317 tweets which most frequently described clinical vignettes or experience (46%) or medical education (25%) related to buprenorphine and had themes related to treatment initiation location (ED vs outpatient vs home) (8.6%) and challenges and solutions to buprenorphine administration (8.6%). CONCLUSIONS A tweetchat can be used to disseminate and discuss the adoption of buprenorphine in the ED. Importantly, the tweetchat provides a forum for experts to share narratives and expertise on implementation and barriers and successes in operationalizing buprenorphine administration in emergency departments.
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Affiliation(s)
- Megan Chenworth
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Emergency Medicine, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer S Love
- Division of Medical Toxicology, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Howard A Greller
- Division of Medical Toxicology, Department of Emergency Medicine, SBH Health Systems, Bronx, NY, USA
| | - Abeed Sarker
- Department of Biomedical Informatics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Peter R Chai
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
- The Fenway Institute, Boston, MA, USA
- The Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Boston, MA, USA
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Schwarz ES, Laes JR, Wiegand TJ. A New Way Forward in the Emergency Department. J Med Toxicol 2019; 15:220-222. [PMID: 31278586 DOI: 10.1007/s13181-019-00718-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8072, Saint Louis, MO, 63144, USA.
| | - JoAn R Laes
- Department of Internal Medicine, Division of Addiction Medicine, Hennepin County Medical Center, Minneapolis, USA
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, USA
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