Training Program Leads to More Buprenorphine Use in ED

A 6-month intensive education program bolstered usage rates of buprenorphine for opioid use disorder (OUD) in the emergency department (ED), a non-randomized trial found.

Compared with a 60-minute grand rounds lecture, centers that underwent the implementation facilitation (IF) strategy increased the rate of ED-initiated buprenorphine from 0.5% to 14.6% among patients meeting criteria for moderate to severe OUD, said Gail D'Onofrio, MD, MS, of Yale School of Medicine in New Haven, Connecticut, and colleagues.

This represented two patients who received this treatment after the grand rounds lecture versus 53 patients during the IF program, out of a total of more than 700 study patients, they reported in JAMA Network Open.

And benefits of IF were sustained, as 16.3% (n=59) of patients were still engaged with OUD treatment 30 days later versus 10.2% (40 patients) prior to this program.

Not surprisingly, patients who received this ED-initiated buprenorphine treatment saw higher treatment rates than those who didn't get this treatment, underscoring how important it is to bump up the rates of administering this treatment in EDs. D'Onofrio's group found that 35.8% of those who got ED-initiated buprenorphine were still in treatment after 30 days versus only 12.9% of those who didn't get this treatment in the ED (19 of 53 patients vs 40 of 309 patients).

With IF, there was a major jump in the number of ED clinicians with an X-waiver, from 11 to 196 clinicians, and this included 161 physicians and 35 advanced practice clinicians. The IF period also saw a significantly higher number of ED visits where buprenorphine was administered or prescribed (1,256 vs 259), unique clinicians that prescribed buprenorphine (449 vs 162), and number of visits where naloxone was dispensed or prescribed (1,091 vs 535).

"Although it is important to be cautious before changing practice on the basis of a single article, it is rare for an intervention to be so impactful, especially for a disease with a high mortality rate and increasing numbers of fatal overdoses," noted Scott Weiner, MD, MPH, of Brigham and Women's Hospital in Boston, and Jason Hoppe, DO, of the University of Colorado School of Medicine in Aurora.

The current study raises questions about next steps for continued improvement of rates of ED buprenorphine use, which is "dishearteningly low," they stated in an accompanying invited commentary.

Weiner and Hoppe compared the rates of buprenorphine use with those of epinephrine for anaphylaxis. "An evaluation of nearly 149,000 ED visits for opioid overdose found that buprenorphine was prescribed after only 8.5% of visits vs ED visits for anaphylaxis, which resulted in an epinephrine autoinjector prescription 48.9% of the time," they said. "Why is there such a disparity in the provision of these life-saving medications?"

The answer is multifactorial, they said, first pointing out that buprenorphine is "a pharmacologically complicated medicine."

"It is possible that buprenorphine treatment is less effective or may lead to more precipitated withdrawal, which may discourage treatment engagement," Weiner and Hoppe suggested, although a recent JAMA Network Open research letter, also from D'Onofrio and colleagues, found this happened less than 1% of the time.

Some clinicians may be hesitant that providing OUD treatment may encourage return visits to the ED due to the stigma associated with the disorder and its treatment. Clinicians may also be wary of the fact that the buprenorphine required a special waiver to prescribe for more than 20 years, although this is no longer the case.

"ED-initiated buprenorphine is a relatively new practice compared with the 2 decades that the medication has been available to treat OUD," noted D'Onofrio's group. "Implementation likely requires strategies at the clinician, patient, health care system, and regulatory levels, and our findings suggest adoption would benefit from additional interventions, such as mandated performance measures."

The educational program in four major health systems: Johns Hopkins Hospital in Baltimore, Mount Sinai Beth Israel in New York, University of Cincinnati Medical Center in Ohio, and Harborview Medical Center in Seattle. Each of these centers clocks over 60,000 annual ED visits.

A total of 756 patients (mean age 39 years, 71.4% male, a majority white) who met Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for moderate to severe OUD were enrolled across all sites, and the study took place from 2017 to 2020. Among enrolled patients, about 80% had positive urine test results for opiates while around half tested positive for fentanyl. About half reported injection drug use in the past month.

The 6-month IF consisted of a wide-range of site-specific education led by the study investigators, including surveys and focus groups with ED and community clinicians, plus ED social workers and counselors, leadership, pharmacists, and patients with OUD, all guided by the Promoting Action on Research Implementation in Health Services framework.

Compared with the program was a 12-month period following one 60-minute grand rounds lecture attended by emergency medicine faculty, residents, and community clinicians. Topics discussed at the lecture included the opioid crisis within the ED, treatment strategies including ED-initiated buprenorphine, harm reduction strategies, and obtaining an X-waiver.

A study limitation was the fact that "the study did not collect information on the number of patients who refused buprenorphine in the ED. Refusal of ED-initiated buprenorphine when offered by the ED clinicians could have resulted in the overall modest rates of receiving this intervention," according to the researchers.

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