Evaluation of a Primary Care-Based Multidisciplinary Transition Clinic for Patients Newly Initiated on Buprenorphine in the Emergency Department

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Peer support for patients with opioid use disorder in the emergency department: A narrative review

Faced with a growing opioid overdose crisis, emergency departments (EDs) are increasingly hiring peers-people with lived experiences of addiction and recovery-to work with patients in the ED who have opioid use disorders (OUDs) or who have experienced an opioid overdose. Despite a clear need for more support for patients with OUD and rapid expansion in grant funding for peer programs, there are limited data on how these programs affect clinical outcomes and how they are best implemented within the ED. In this narrative review, we synthesize the existing evidence on how to develop and implement peer programs for OUD in the ED setting. We describe the key activities peers can undertake in the ED, outline requirements of the peer role and best practices for peer supervision and hiring, detail how ED administrators have built financial and political support for peer programs, and summarize the limited evidence on clinical and care linkage outcomes of peer programs. We highlight key resources that ED clinicians and administrators can use to develop peer programs and key areas where additional research is needed.

Knowledge, Attitudes, and Beliefs About Opioid Use Disorder Treatment in Primary Care

This survey study assesses the US public’s perception and awareness regarding medication for opioid use disorder and its availability in primary care settings.

Analysis of rising cases of adolescent opioid use presentations to the emergency department and their management

OBJECTIVE

We sought to answer the question of how adolescents (ages 12-17 years old) with opioid-related presentations are currently managed in the ED. The two main outcomes were the proportion of visits where naloxone and buprenorphine were both used and prescribed, and the rate of revisits to the emergency department in the six months following ED presentation.

METHODS

This was a multi-center retrospective cross-sectional study. We studied patients presenting to the ED who were 12-17 years old with an opioid-related presentation.

RESULTS

Two-hundred and thirty-one patients were identified out of 571 encounters screened. Of these presentations, 77/231 (33%) were girls and 154/231 (67%) were boys. The majority of patients were Latino (64%; n=147); 26% were white (n=59), 6% were middle eastern or Arab (14), and 4% were black (10). Incidence of opioid use disorder per 100,000 presentations increased by 2800% from 2014 to 2022 (21/100,000 +/- 10 [2014] to 600/100,000 +/- 50 [2022]). A plurality of cases was related to opioid withdrawal (42%; 97). On discharge from the ED, 29% of patients received naloxone. For patients in withdrawal, 4% received a prescription for buprenorphine. Twenty-nine percent of patients had a return to the ED in the six months following initial visit.

CONCLUSIONS

Adolescent opioid-related presentations to the ED are rapidly increasing. Increasing ED presentations, compounded by a high 6-month revisit rate, pose a management challenge amid limited outpatient resources for this population. Opioid agonist therapy and naloxone are not routinely provided. Increasing the use of both are two ways to improve the quality of care for this population.