Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine

Considerations and limitations of buprenorphine prescribing for opioid use disorder in the intensive care unit setting: A narrative review

PURPOSE

The purpose of this review is to discuss important considerations when prescribing buprenorphine for opioid use disorder (OUD) in the intensive care unit (ICU) setting, recognizing the challenges of providing detailed recommendations in the setting of limited available evidence.

SUMMARY

Buprenorphine is a partial mu-opioid receptor agonist that is likely to be increasingly prescribed for OUD in the ICU setting due to the relaxation of prescribing regulations. The pharmacology and pharmacokinetics of buprenorphine are complicated by the availability of several formulations that can be given by different administration routes. There is no single optimal dosing strategy for buprenorphine induction, with regimens ranging from very low-dose to high dose regimens. Faster induction with higher doses of buprenorphine has been studied and is frequently utilized in the emergency department. In patients admitted to the ICU who were receiving opioids either medically or illicitly, analgesia will not occur until their baseline opioid requirements are covered when their preadmission opioid is either reversed or interrupted. For patients in the ICU who are not on buprenorphine at the time of admission but have possible OUD, there are no validated tools to diagnose OUD or the severity of opioid withdrawal in critically ill patients unable to provide the subjective components of instruments validated in outpatient settings. When prescribing buprenorphine in the ICU, important issues to consider include dosing, monitoring, pain management, use of adjunctive medications, and considerations to transition to outpatient therapy. Ideally, addiction and pain management specialists would be available when buprenorphine is prescribed for critically ill patients.

CONCLUSION

There are unique challenges when prescribing buprenorphine for OUD in critically ill patients, regardless of whether they were receiving buprenorphine when admitted to the ICU setting for OUD or are under consideration for buprenorphine initiation. There is a critical need for more research in this area.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Management of Critically Ill Patients Receiving Medications for Opioid Use Disorder

TOPIC IMPORTANCE

Critical care clinicians are likely to see an increasing number of patients admitted to the ICU who are receiving US Food and Drug Administration-approved medications for opioid use disorder (MOUDs) given the well-documented benefits of these agents. Oral methadone, multiple formulations of buprenorphine, and extended-release naltrexone are the three types of MOUD most likely to be encountered by ICU clinicians; however, these drugs vary with respect to formulations, pharmacokinetics, and adverse effects.

REVIEW FINDINGS

No published clinical practice guidelines or consensus statements are available to guide decision-making in patients admitted to the ICU setting who are receiving MOUDs before admission. Additionally, no randomized trials and limited observational studies have evaluated issues related to MOUD use in the ICU. Therefore, ICU clinicians caring for patients admitted who are taking MOUDs must base their decision-making on data extrapolation from pharmacokinetic, pharmacologic, and clinical studies performed in non-ICU settings.

SUMMARY

Despite the challenges in administering MOUDs in critically ill patients, extrapolation of data from other hospital settings suggests that the benefits of continuing MOUD therapy outweigh the risks in patients able to continue therapy. This article provides guidance for critical care clinicians caring for patients admitted to the ICU already receiving methadone, buprenorphine, or extended-release naltrexone. The guidance includes algorithms to aid clinicians in the clinical decision-making process, recognizing the inherent limitations of the existing evidence on which the algorithms are based and the need to account for patient-specific considerations.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementing Programs to Initiate Buprenorphine for Opioid Use Disorder Treatment in High-Need, Low-Resource Emergency Departments: A Nonrandomized Controlled Trial

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.

Implementation of a hospital-based intervention for MOUD initiation and referral to a Bridge Clinic for opioid use disorder

INTRODUCTION

Individuals struggling with opioid use disorder (OUD) utilize the adult emergency department (ED) and psychiatric emergency department at high rates. In 2019, Vanderbilt University Medical Center created a system for individuals identified in the emergency department with OUD to transition care to a Bridge Clinic for up to three months of comprehensive behavioral health treatment, alongside primary care, infectious diseases, and pain management, regardless of their insurance status.

METHODS

We conducted 20 interviews with patients enrolled in treatment in our Bridge Clinic and 13 providers in the psychiatric emergency department and emergency department. Our provider interviews focused on understanding experiences identifying people with OUD and referring them to care at the Bridge Clinic. Our patient interviews focused on understanding their experiences of care-seeking, the referral process, and their satisfaction with treatment at the Bridge Clinic.

RESULTS

Our analysis generated 3 major themes around patient identification, referral, and quality of care from providers and patients. The study found general agreement between both groups around the high quality of care delivered in the Bridge Clinic compared with OUD treatment at nearby treatment facilities, specifically because it offered a stigma-free environment for the delivery of medication for addiction therapy and psychosocial support. Providers highlighted the lack of a systematic strategy for identifying people with OUD in an ED setting. They also found the referral process cumbersome because it could not be done through EPIC and there were limited patient slots available. In contrast, patients reported a smooth and simple referral from the ED to the Bridge Clinic.

CONCLUSIONS

Creating a Bridge Clinic for comprehensive OUD treatment at a large university medical center has been challenging but has resulted in the creation of a comprehensive care system that prioritizes quality care. Funding to increase the number of patient slots available, coupled with an electronic system of patient referral, will increase the reach of the program to some of Nashville's most vulnerable constituents.

METHADONE INITIATION IN THE EMERGENCY DEPARTMENT FOR OPIOID USE DISORDER: A CASE SERIES

BACKGROUND

In an era of fentanyl and continually rising rates of opioid overdose deaths, increasing access to evidence-based treatment for opioid use disorder (OUD) should be prioritized. Emergency department (ED) buprenorphine initiation for patients with OUD is considered best-practice. Methadone, though also evidence-based and effective, is under-utilized due to strict federal regulation, significant stigma, and lack of physician training. We describe the novel utilization of CFR Title 21 1306.07 (b), also known as the "72-hour rule," to initiate methadone for OUD in the ED.

CASE SERIES

We describe the cases of 3 patients with a history of OUD who were initiated on methadone for OUD in the ED, linked to an opioid treatment program, and attended an intake appointment. Why Should an Emergency Physician Be Aware of This? The ED can be a crucial point of intervention for vulnerable patients with OUD who may not interact with the health care system in other settings. Methadone and buprenorphine are both first-line options for medication for OUD, and methadone may be preferred in patients who have been unsuccessful with buprenorphine in the past or those at higher risk of treatment dropout. Patients may also prefer methadone to buprenorphine based on previous experience or understanding of the medications. ED physicians may utilize the "72-hour rule" to administer and initiate methadone for up to 3 consecutive days while arranging referral to treatment. EDs can develop methadone initiation and bridge programs utilizing similar strategies to those that have been described in developing buprenorphine programs.

Novel uses of ketamine in the emergency department

INTRODUCTION

: Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting.

AREAS COVERED

: This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation.

EXPERT OPINION

: Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.

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

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.

Resident attitudes, experiences, and preferences on initiating buprenorphine in the emergency department: A national survey

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.

Emergency Department-initiated Buprenorphine and Referral to Follow-up Addiction Care: A Program Description

INTRODUCTION

Emergency department (ED) initiated opioid use disorder (OUD) care is effective; however, real-world predictors of patient engagement are lacking.

OBJECTIVE

This program evaluation examined predictors of ED-based OUD treatment and subsequent engagement.

METHOD

Program evaluation in Boston, MA. Adult patients who met criteria for OUD during an ED visit in 2019 were included. Patients were included if a diagnosis of OUD or opioid-related overdose was associated with the ED visit or if they met previously validated criteria for OUD within the previous 12 months. We assessed predictors of ED-OUD treatment receipt and subsequent engagement, using Healthcare Effectiveness Data and Information Set definition of initial encounter within 14 days of discharge and either 2 subsequent encounters or a subsequent buprenorphine prescription within 34 days of the initial encounter. We used generalized estimating equations for panel data.

RESULTS

During 2019, 1946 patients met criteria for OUD. Referrals to Bridge Clinic were made for 207 (11%), buprenorphine initiated for 106 (5%), and home induction buprenorphine kits given to 56 (3%). Following ED discharge, 237 patients (12%) had a visit within 14 days, 122 (6%) had ≥2 additional visits, and 207 (11%) received a subsequent buprenorphine prescription. Young, White, male patients were most likely to receive ED-OUD care. Patients who received ED-OUD care were more likely to have subsequent treatment engagement (adjusted rate ratio: 2.30, 95% confidence intervals: 1.62-3.27). Referrals were made less often than predicted for Black (-49%) or Hispanic/Latinx (-25%) patients.

CONCLUSIONS

Initiating treatment for OUD in the ED was associated with increased engagement in outpatient addiction care.

Opioid overdose survivors: Medications for opioid use disorder and risk of repeat overdose in Medicaid patients

BACKGROUND

Patients with medically-treated opioid overdose are at high risk for subsequent adverse outcomes, including repeat overdose. Understanding factors associated with repeat overdose can aid in optimizing post-overdose interventions.

METHODS

We conducted a longitudinal, retrospective cohort study using NJ Medicaid data from 2014 to 2019. Medicaid beneficiaries aged 12-64 with an index opioid overdose from 2015 to 2018 were followed for one year for subsequent overdose. Exposures included patient demographics; co-occurring medical, mental health, and substance use disorders; service and medication use in the 180 days preceding the index overdose; and MOUD following index overdose.

RESULTS

Of 4898 individuals meeting inclusion criteria, 19.6% had repeat opioid overdoses within one year. Index overdoses involving heroin/synthetic opioids were associated with higher repeat overdose risk than those involving prescription/other opioids only (HR = 1.44, 95% CI = 1.22-1.71). Risk was higher for males and those with baseline opioid use disorder diagnosis or ED visits. Only 21.7% received MOUD at any point in the year following overdose. MOUD was associated with a large decrease in repeat overdose risk among those with index overdose involving heroin/synthetic opioids (HR = 0.30, 95% CI = 0.20-0.46). Among those receiving MOUD at any point in follow-up, 10.5% (112/1065) experienced repeat overdose versus 22.1% (848/3833) for those without MOUD.

CONCLUSIONS

Repeat overdose was common among individuals with medically-treated opioid overdose. Risk factors for repeat overdose varied by type of opioid involved in index overdose, with differential implications for intervention. MOUD following index opioid overdose involving heroin/synthetic opioids was associated with reduced repeat overdose risk.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

IMPORTANCE

Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment.

OBJECTIVE

To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019.

MAIN OUTCOMES AND MEASURES

Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements.

RESULTS

A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training.

CONCLUSIONS AND RELEVANCE

In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.

"This is part of emergency medicine now": A qualitative assessment of emergency clinicians' facilitators of and barriers to initiating buprenorphine

OBJECTIVES

Despite evidence demonstrating the safety and efficacy of buprenorphine for the treatment of emergency department (ED) patients with opioid use disorder (OUD), incorporation into clinical practice has been highly variable. We explored barriers and facilitators to the prescription of buprenorphine, as perceived by practicing ED clinicians.

METHODS

We conducted semistructured interviews with a purposeful sample of ED clinicians. An interview guide was developed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework implementation science frameworks. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized.

RESULTS

We interviewed 25 ED clinicians from 11 states in the United States. Participants were diverse with regard to years in practice and practice setting. While outer setting barriers such as the logistic costs of getting a DEA-X waiver and lack of clear follow-up for patients were noted by many participants, individual-level determinants driven by emotion (stigma), beliefs about consequences and roles, and knowledge predominated. Participants' responses suggested that implementation strategies should address stigma, local culture, knowledge gaps, and logistic challenges, but that a particular order to addressing barriers may be necessary.

CONCLUSIONS

While some participants were hesitant to adopt a "new" role in treating patients with medications for OUD, many already had and gave concrete strategies regarding how to encourage others to embrace their attitude of "this is part of emergency medicine now."

Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment

Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.

Methadone and suboxone® mentions on twitter: thematic and sentiment analysis

BACKGROUND

According to the latest medical evidence, Methadone and buprenorphine-naloxone (Suboxone®) are effective treatments for opioid use disorder (OUD). While the evidence basis for the use of these medications is favorable, less is known about the perceptions of the general public about them.

OBJECTIVE

This study aimed to use Twitter to assess the public perceptions about methadone and buprenorphine-naloxone, and to compare their discussion contents based on themes/topics, subthemes, and sentiment.

METHODS

We conducted a descriptive analysis of a small and automatic analysis of a large volume of microposts ("tweets") that mentioned "methadone" or "suboxone". In the manual analysis, we categorized the tweets into themes and subthemes, as well as by sentiment and personal experience, and compared the information posted about these two medications. We performed automatic topic modeling and sentiment analysis over large volumes of posts and compared the outputs to those from the manual analyses.

RESULTS

We manually analyzed 900 tweets, most of which related to access (15.3% for methadone; 14.3% for buprenorphine-naloxone), stigma (17.0%; 15.5%), and OUD treatment (12.8%; 15.6%). Only a small proportion of tweets (16.4% for Suboxone® and 9.3% for methadone) expressed positive sentiments about the medications, with few tweets describing personal experiences. Tweets mentioning both medications primarily discussed MOUD broadly, rather than comparing the two medications directly. Automatic topic modeling revealed topics from the larger dataset that corresponded closely to the manually identified themes, but sentiment analysis did not reveal any notable differences in chatter regarding the two medications.

CONCLUSIONS

Twitter content about methadone and Suboxone® is similar, with the same major themes and similar sub-themes. Despite the proven effectiveness of these medications, there was little dialogue related to their benefits or efficacy in the treatment of OUD. Perceptions of these medications may contribute to their underutilization in combatting OUDs.

Continuation of outpatient buprenorphine therapy after dispensing Buprenorphine-Naloxone from the emergency department

BACKGROUND

Patients with opioid use disorder (OUD) are frequently seen in the ED for opioid-related reasons, which creates an opportunity for ED providers to discuss medications for OUD with their patients. Buprenorphine is a partial mu-opioid agonist that is FDA approved to treat OUD and may be initiated in the ED. Traditionally, buprenorphine therapy was initiated under healthcare provider observation; however, other strategies such as at-home induction have also emerged.

METHODS

This was a retrospective descriptive analysis of patients aged 18 years or older who received a take-home supply of buprenorphine-naloxone from an urban, academic ED between March 2018 and March 2020. The primary outcome was the proportion of patients who filled a prescription for buprenorphine at three months after index ED visit. The proportion of patients that filled a prescription for buprenorphine at six months was also evaluated. The primary safety endpoint was the proportion of patients with return ED visit within six months related to opioid overdose.

RESULTS

There were 242 patient records reviewed with 155 patients included in final analysis. Seventy (45.2%) patients filled buprenorphine prescriptions at three months, with 64 (41.3%) who filled buprenorphine prescriptions at six months. Seventeen (11%) patients had a return ED visit related to opioid overdose within six months.

CONCLUSION

Dispensing buprenorphine take-home kits from the ED resulted in continuation of outpatient buprenorphine in almost 50% of patients. Further studies are warranted to define the role of ED-dispensed buprenorphine.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

Sedation - Effects of disorders of abuse on therapeutic efficacy (SEDATE): A retrospective cohort study

BACKGROUND

The impact of alcohol or opioid use disorders on medication dosing for procedural sedation in the emergency department (ED) is unclear, as most of the literature is from gastrointestinal endoscopy. Exploring how these patient factors affect sedative and analgesic medications may inform more nuanced sedation strategies in the emergency department.

METHODS

This was a retrospective chart-review cohort study across five EDs from 2015 to 2020. Included were adult patients who underwent procedural sedation in the ED, categorized into three a priori groups: alcohol use disorder (AUD), opioid use disorder (OUD), and individuals with neither (non-SUD). Wilcoxon test was used to compare the time-averaged dose of agents between groups. Logistic regression was used to model multi-agent sedations. The propofol time-averaged dose was the primary outcome. Secondary outcomes included other agents, sedation duration, and switching to other agents.

RESULTS

2725 sedations were included in the analysis. 59 patients had a history of AUD, and 40 had a history of OUD. Time-averaged doses of medications did not differ significantly between AUD and non-SUD patients. Likewise, patients with OUD did not receive different doses of medications compared to non-SUD. The propofol doses for non-SUD, AUD, and OUD were 0.033 IQR 0.04; 0.042 IQR 0.05; and 0.058 IQR 0.04 mg/kg*min, respectively. Sedation duration was not different across groups. Having AUD or OUD is not associated with increased odds of requiring multiple sedative agents.

CONCLUSION

Although sedation in patients with AUD or OUD may be associated with significant case bias, these patient factors did not significantly alter outcomes compared to the general population. This study suggests there is no evidence to proactively adjust medication strategy in ED patients with AUD or OUD.

Advancing emergency department-initiated buprenorphine

Opioids are the main driver of drug overdose deaths in the United States, and there has been a marked increase in opioid-related overdoses during the COVID-19 public health emergency. Many emergency departments (EDs) across the country are implementing ED-initiated buprenorphine programs, and this is a method to address and prevent opioid overdoses. Resources are available to overcome barriers and take action.

Emergency department-based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches?

BACKGROUND

The opioid epidemic remains a public health crisis and most people with opioid use disorder (OUD) do not receive effective treatment. The emergency department (ED) can be a critical entry point for treatment. EDs are developing and implementing ED-based efforts to address OUD to improve access to OUD treatment. This study's objective is to identify features of ED-based OUD treatment programs that relate to program implementation, effectiveness, and sustainability.

METHODS

We obtained data through literature review and semistructured interviews with ED physicians and leaders. The study analyzed these data to develop a framework of key components of ED-based efforts and highlight barriers and facilitators to implementation and program effectiveness.

RESULTS

We identify five key features of ED-based opioid treatment programs that vary across programs and may influence effectiveness and impact: patient identification methods; treatment approaches; program structure; relationship with community partners; and financing and sustainability. Successful implementation of ED-based OUD treatment includes having a champion, a reliable referral network, and systematic tracking and reporting of data for monitoring and feedback.

CONCLUSION

Going forward, attention to these features may help to improve effectiveness. As researchers conduct studies of ED-based care models, they should assess the impact of variation in key features to improve program effectiveness.

California Poison Control System Implementation of a Novel Hotline to Treat Patients with Opioid Use Disorder

INTRODUCTION

In response to the opioid epidemic, California state officials sought to fund a variety of projects aimed at reducing opioid-related deaths. We describe the California Poison Control System's (CPCS) successful effort in integrating itself into the state's public health response to the opioid epidemic and describe poison control center staff attitudes and perceptions regarding the role of poison control centers at treating opioid withdrawal and addiction.

METHODS

The CPCS created a leadership team and a separate 24/7 hotline, called the CPCS-Bridge line, to field calls from frontline health care providers interested in initiating medications for opioid use disorder for their patients. The implementation process also included training of all CPCS staff. In addition, the leadership team conducted an anonymous survey study to analyze attitudes and perceptions of poison center staff on the role of the poison center in the management of opioid use disorder. Descriptive statistics were used to characterize the data.

RESULTS

Calls to the new hotline increased over time, along with CPCS-initiated outreach and advertisement. A majority of questions received by the hotline were related to uncomplicated buprenorphine starts in special populations. A pre-training survey was completed by 27 (58%) of CPCS specialists, many of whom had no prior experience treating patients with opioid use disorder. Only one specialist (2%) did not believe that poison centers should play a role in opioid addiction.

CONCLUSIONS

The California Poison Control System successfully created a hotline to assist frontline health care providers in treating patients with opioid use disorder and highlight the critical role of poison centers in the public health domain. Increased federal funding to poison centers is likely to be mutually beneficial to all parties involved.

Physician attitudes on buprenorphine induction in the emergency department: results from a multistate survey

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.

Impact of Social Distancing on Individuals Who Use Drugs: Considerations for Emergency Department Providers

The isolation that comes from social distancing during the COVID-19 pandemic can be particularly detrimental to the United States’ population of people who use drugs. People with substance use disorders may be at risk for return to use, exacerbation of existing mental health disorders, and risky drug practices. In this commentary, we review the risk to people who use drugs and how emergency department providers can best support these individuals during the unprecedented time of social distancing.