80% of ED clinicians feel unready to initiate buprenorphine for opioid use disorder
Few ED clinicians expressed readiness to initiate buprenorphine for the treatment of opioid use disorder, according to study results published in JAMA Network Open.
“This is a baseline evaluation for a larger implementation study, Project ED Health, that aims to use implementation facilitation to support development of programs to initiate treatment for opioid use disorder among four urban, academic EDs,” Kathryn F. Hawk, MD, of the department of emergency medicine at Yale School of Medicine, told Healio Psychiatry. “We identified key barriers and facilitators to the treatment initiation and outpatient referral for ED patients with opioid use disorder. This evaluation was used to develop and tailor our implementation facilitation support to enhance the development of programs to initiate treatment for opioid use disorder at each of the sites, which is the overall objective of Project ED Health.”
Although numerous studies and clinical guidelines have supported the use of buprenorphine and methadone to treat opioid use disorder, as many as 80% of patients do not receive these treatments, the researchers noted. Further, previous studies showed that when patients with opioid use disorder received ED-initiated buprenorphine treatment with referral to ongoing care, they were more likely to experience addiction treatment engagement, and the process proved cost-effective. However, adoption of ED-initiated buprenorphine across the United States has been limited.
Hawk and colleagues sought to characterize facilitators and barriers to buprenorphine initiation readiness for treating opioid use disorder in the ED, as well as to identify opportunities for promoting readiness across several clinician types. They conducted a mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health services framework and included four geographically diverse academic EDs. They collected data via electronically distributed surveys of 113 attending physicians, 107 residents and 48 advanced practice clinicians. A subset of 74 respondents participated in one of 11 focus group discussions. The researchers used a visual analog scale to assess clinician readiness to initiate buprenorphine and provide referral for ongoing treatment. They dichotomized respondents with scores of 0 to 6 as less ready and those with scores of 7 to 10 as most ready. Using an ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups, they assessed ratings and perspectives on evidence and context-related factors to promote buprenorphine initiated in the ED with referral for ongoing treatment, respectively.
Results showed 56 (20.9%) of 268 respondents expressed readiness to initiate buprenorphine for patients with opioid use disorder admitted to the ED. Further, nine (3.5%) of 258 reported having completed Drug Addiction Treatment Act of 2000 training. Clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Context subscales compared with those who were less ready, with a range of 3.5 (95% CI, 3.35-3.65) to 4.33 (95% CI, 4.13-4.53) vs. 3.11 (95% CI, 3.03-3.2) to 3.6 (95% CI, 3.49-3.7), as well as on the Slack Resources of the ORCA Context Subscales, with a range of 3.32 (95% CI, 3.08-3.55) vs. 3 (95% CI, 2.87-3.12).
Clinicians reported several barriers to ED-initiated buprenorphine, including:
- lack of training and experience in treating opioid use disorder with buprenorphine;
- concerns about ability to link to ongoing care; and
- competing needs and priorities for ED time and resources.
“Key barriers that need to be overcome to effectively initiate buprenorphine in the ED can be addressed by developing tailored treatment protocols, providing multidisciplinary ED staff training, providing feedback to staff about patients who were successfully linked to treatment and by establishing relationships with specific outpatient referral sites,” Hawk told Healio Psychiatry. – by Joe Gramigna
Disclosures: Hawk reports grants from the National Institute on Drug Abuse/NIH during the conduct of this study. Please see the study for all other authors’ relevant financial disclosures.