Emergency departments slow to adopt proven opioid use disorder therapy
A new study by Yale researchers looking at nearly 400 clinicians at four urban academic emergency departments found that, despite scientific evidence supporting the benefits of buprenorphine for opioid use disorder, just 21% of emergency department clinicians indicated readiness to offer it to patients in need.
The study, which appears in the May 11 issue of JAMA Network Open, involved emergency departments at Mt. Sinai Hospital in Manhattan, the Johns Hopkins Hospital in Baltimore, Harborview Medical Center in Seattle, and University of Cincinnati Medial Center.
The study is the first installment in Project ED Health, an implementation study funded by the National Institute on Drug Abuse Clinical Trials Network to support strategies for increasing buprenorphine prescriptions in emergency departments. Buprenorphine, a partial opioid agonist—a drug that activates opioid receptors in the brain to a lesser degree than oxycodone and morphine—is safe to administer, relieves withdrawal symptoms, and can prevent overdose, according to years of established medical research. An implementation study reveals barriers to adopting research findings.
Project ED Health is led by two Yale physician-researchers, Dr. Gail D'Onofrio, professor and chair of the department of emergency medicine and Dr. David Fiellin, professor of internal medicine and director of the Yale Program in Addiction Medicine.
"This study provides a baseline evaluation of what care emergency departments are providing to patients with opioid use disorder," said lead author Dr. Kathryn Hawk, assistant professor in emergency medicine and attending physician in the Yale New Haven Hospital Emergency Department.
Despite barriers, clinicians are willing to give buprenorphine to patients in the emergency department, provided that they receive sufficient support and training, the study found.
"The willingness of emergency department providers to take on a new treatment is changing drastically," said Hawk.
Researchers conducted the study between April 2018 and January 2019. A team of addiction medicine physicians met with providers at the hospitals, including doctors, advance practice providers (APPs), and emergency medicine residents. Providers participated in a web-based anonymous survey that collected data about their demographics, training, experiences with ED-initiated buprenorphine, and readiness to administer buprenorphine for opioid use disorder on a scale of one to 10. Providers then rated their work culture, clinical experience, and perceived patient needs. Later, the study team ran focus groups to better understand factors impacting buprenorphine prescribing in the ED.
The researchers found that barriers to providing buprenorphine included lack of formal training, limitations on time, limited knowledge of local treatment resources, absence of local protocols and referral networks, and perceptions that initiating buprenorphine therapy falls outside the scope and practice of emergency medicine.
One resident physician quoted in the study said: "Trying to suss out which of those patients might be appropriate for initiating some therapy and which aren't is a skill that I don't have. I don't think that it's a skill that we're necessarily being trained for right now."
There was also confusion about required waivers. Just 3% of providers interviewed had DATA 2000 (x-waiver) training for buprenorphine. Providers need the waiver, which requires eight hours of approved training for physicians and 24 hours for APPs, to write a prescription for buprenorphine to be filed at a pharmacy. Emergency providers can give buprenorphine in the ED without the special waiver, said Hawk, but added that they "needed clarification around what they can and can't do."
Historically, emergency departments have not been thought of as places where patients are treated for opioid use disorder, she said. Typically, those patients were referred to outpatient clinics for treatment.
"The opioid epidemic has really changed that," Hawk said.
In 2015, Yale researchers published a landmark study in JAMA that found that patients admitted to emergency departments for opioid use disorder who were treated with buprenorphine along with medical management in primary care were twice as likely than patients not given buprenorphine to remain in addiction treatment one month later.
"The big message of that study was that initiating treatment in the ED setting was very effective," said D'Onofrio, "but true adoption lagged. So now we're trying to understand why that is, and how we can improve implementation of this best practice."
This latest study found that in order to improve adoption of ED-initiated buprenorphine there needs to be more education and training, established protocols, and enhanced communication across different stakeholder groups.
"We believe these findings will be valuable for other EDs working to enhance delivery of buprenorphine, a life-saving medication that should be available as a treatment option for all patients with untreated opioid use disorder walking into an ED," said Dr. Jennifer Edelman, associate professor of internal medicine and senior author on the study.