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Seliski N, Madsen T, Eley S, Colosimo J, Engar T, Gordon A, Barnett C, Humiston G, Morsillo T, Stolebarger L, Smid MC, Cochran G. Implementation of a rural emergency department-initiated buprenorphine program in the mountain west: a study protocol. Addict Sci Clin Pract 2024; 19:63. [PMID: 39228007 PMCID: PMC11369999 DOI: 10.1186/s13722-024-00496-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 08/19/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Opioid related overdose morbidity and mortality continue to significantly impact rural communities. Nationwide, emergency departments (EDs) have seen an increase in opioid use disorder (OUD)-related visits compared to other substance use disorders (SUD). ED-initiated buprenorphine is associated with increased treatment engagement at 30 days. However, few studies assess rural ED-initiated buprenorphine implementation, which has unique implementation barriers. This protocol outlines the rationale and methods of a rural ED-initiated buprenorphine program implementation study. METHODS This is a two-year longitudinal implementation design with repeated qualitative and quantitative measures of an ED-initiated buprenorphine program in the rural Mountain West. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework outlines intervention assessments. The primary outcome is implementation measured by ED-initiated buprenorphine protocol core components. Reach, adoption, and maintenance are secondary outcomes. External facilitators from an academic institution with addiction medicine and prior program implementation expertise partnered with community hospital internal facilitators to form an implementation team. External facilitators provide ongoing support, recommendations, education, and academic detailing. The implementation team designed and implemented the rural ED-initiated buprenorphine program. The program includes OUD screening, low-threshold buprenorphine initiation, naloxone distribution and administration training, and patient navigator incorporation to provide warm hand off referrals for outpatient OUD management. To address rural based implementation barriers, we organized implementation strategies based on Expert Recommendations for Implementing Change (ERIC). Implementation strategies include ED workflow redesign, local needs assessments, ED staff education, hospital leadership and clinical champion involvement, as well as patient and community resources engagement. DISCUSSION Most ED-initiated buprenorphine implementation studies have been conducted in urban settings, with few involving rural areas and none have been done in the rural Mountain West. Rural EDs face unique barriers, but tailored implementation strategies with external facilitation support may help address these. This protocol could help identify effective rural ED-initiated buprenorphine implementation strategies to integrate more accessible OUD treatment within rural communities to prevent further morbidity and mortality. TRIAL REGISTRATION ClinicalTrials.gov National Clinical Trials, NCT06087991. Registered 11 October 2023 - Retrospectively registered, https://clinicaltrials.gov/study/NCT06087991 .
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Affiliation(s)
- Natasha Seliski
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Suite A, Salt Lake City, UT, 84108, USA.
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, 50 N. Medical Drive, Salt Lake City, UT, 84132, USA
- Wound Care and Hyperbaric Medicine, St. Mark's Hospital, 1200 East 3900 South #G175, Salt Lake City, UT, 8412, USA
| | - Savannah Eley
- Castleview Hospital, 300 N Hospital Drive, Price, UT, 84501, USA
| | | | - Travis Engar
- Castleview Hospital, 300 N Hospital Drive, Price, UT, 84501, USA
| | - Adam Gordon
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | | | - Grace Humiston
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
| | - Taylor Morsillo
- Utah Department of Health and Human Services, 195 North, West, Salt Lake City, UT, 1950, 84116, USA
| | - Laura Stolebarger
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, School of Medicine, University of Utah Health, 30 North 1900 East #2B200, Salt Lake City, UT, 84132, USA
| | - Gerald Cochran
- Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, Program for Addiction Research, University of Utah School of Medicine, 30 North Mario Capecchi Drive, 3rd Floor North, Salt Lake City, UT, 84112, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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Comstock G, Truszczynski N, Michael SS, Hoppe J. Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics. West J Emerg Med 2024; 25:483-489. [PMID: 39028234 PMCID: PMC11254146 DOI: 10.5811/westjem.18019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 12/27/2023] [Accepted: 02/28/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics. Methods We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates. Results There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020-May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment. Conclusion Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.
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Affiliation(s)
- Grant Comstock
- Medical College of Wisconsin, Department of Emergency Medicine, Division of Medical Toxicology, Milwaukee, Wisconsin
| | | | - Sean S. Michael
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Jason Hoppe
- University of Colorado School of Medicine, Department of Emergency Medicine, Division of Medical Toxicology and Pharmacology, Aurora, Colorado
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Watson DP, Staton MD, Gastala N. Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites. Addict Sci Clin Pract 2022; 17:41. [PMID: 35902890 PMCID: PMC9331574 DOI: 10.1186/s13722-022-00324-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI). METHODS We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy. RESULTS We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans. CONCLUSIONS Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.
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Affiliation(s)
- Dennis P. Watson
- grid.413870.90000 0004 0418 6295Chestnut Health Systems, 221 W. Walton St, Chicago, IL 60610 USA ,grid.185648.60000 0001 2175 0319Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
| | - Monte D. Staton
- grid.185648.60000 0001 2175 0319Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
| | - Nicole Gastala
- grid.185648.60000 0001 2175 0319Mile Square Health Centers, Department of Family Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
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