It’s a scene that’s repeated countless times every day across the U.S. Siren blaring, an ambulance jolts to a stop at the entrance to a hospital emergency department (ED). Two paramedics jump out, open the back door, retrieve a young man strapped on a gurney, and wheel the gurney into the ED.
A doctor hurries over. The lead paramedic calls out, “Apparent heroin OD; naloxone, 4 mg intranasally, 3 minutes ago. Unconscious, breathing . . . ”
The patient is whisked into an examining room, given another 4 mg naloxone . . . A few minutes later he opens his eyes and looks around the room . . .
§ § §
Another life has been saved—for now. The patient will be monitored until he has fully recovered—and what happens next could mean the difference between life and death.
The Choices
The ED staff have choices. One choice, the usual one, is to send the patient home, perhaps with some brochures and phone numbers.
But discharging someone after an opioid overdose, without offering medication treatment, could mean losing a chance to save a life. A study published in June in Annals of Emergency Medicine found that more than 5% of patients treated in an ED for a nonfatal overdose (OD) died within the year—many of them within the first few weeks. About two-thirds of the deaths were the direct result of an opioid-related overdose.
With treatment, the story is very different. Citing a study in Annals of Internal Medicine, a news release from the National Institutes of Health reported that patients given methadone in the ED after a nonfatal OD were 59% less likely to die within a year, and those given buprenorphine were 38% less likely to do so.
The problem? Readiness. A research team headed by Yale investigators asked ED clinicians to use a visual analog scale to evaluate their readiness to initiate treatment onsite. Of 258 ED clinicians who responded, only 56 (20.9%) rated their readiness to initiate buprenorphine as 7 or more on the scale (less ready, 0-6; most ready, 7-10).
Background
About 2 million people in the U.S. have an opioid use disorder (OUD). It’s long been known that treatment with methadone or buprenorphine can decrease opioid use and help prevent opioid-related illness and death. Yet, according to the Yale team, “as many as 80% of patients do not receive such potentially life-saving treatments.”
The ED is an ideal place to identify OUD and start treatment. All licensed ED clinicians can dispense buprenorphine in the ED; clinicians who hold a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver can also prescribe buprenorphine to OUD outpatients. https://www.samhsa.gov/medication-assisted-treatment/training-materials-resources/apply-for-practitioner-waiver. That’s not the case with methadone; OUD patients can be treated with methadone only in opioid treatment programs.
And studies have shown that starting buprenorphine treatment in the ED and following it with referral for ongoing care is a cost-effective way to promote patients’ involvement in addiction treatment. So, given the opportunity to help save many lives, why are most ED clinicians reluctant to proceed?
The Yale team set out to find the answer.
The Study
Their paper, published May 11 in JAMA Network Open, represents the first installment of an ongoing study, Project ED Health. Study sites are four academic urban EDs: Mt. Sinai Hospital in Manhattan, the Johns Hopkins Hospital in Baltimore, University of Cincinnati Medical Center, and Harborview Medical Center in Seattle.
Project ED Health
Project ED Health is an ongoing study funded by the National Institute on Drug Abuse Center for the Clinical Trials Network. The study was established to identify key implementation strategies to increase buprenorphine prescribing in EDs.
Leading Project ED Health are two of the 16 authors of this JAMA Network Open study: Gail D’Onofrio, MD, professor and chair of the Yale Department of Emergency Medicine, and David Fiellin, MD, professor and director of the Yale Program in Addiction Medicine.
The main points of the study are summarized below.
Objective
- Identify barriers that interfere with ED clinicians’ willingness to start buprenorphine treatment for OUD
- Identify opportunities to promote readiness to treat among multiple types of ED clinicians
Design
- 396 ED clinicians received the surveys electronically
- Data collection: April 1, 2018 ─ January 11, 2019
- Data analysis: June 1, 2018 ─ February 22, 2020
- Evaluation: mixed methods, grounded in the framework of Promoting Action on Research Implementation in Health Services (PARIHS)
https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2389-notes.pdf
Participants and Results
Responding to the survey were 268 clinicians:
- Attending physicians ▬ 113
- Resident physicians ▬ 107
- APCs in academic EDs* ▬ 48
*Advanced practice clinicians (physician assistants [PAs] and nurse practitioners [NPs]).
A subset of 74 participants—37 attending physicians, 25 residents, and 12 APCs—took part in faculty, resident, or APC focus group discussions.
Clinicians’ Readiness
Investigators used a visual analog scale to assess clinicians’ readiness—“less ready” versus “most ready”—to start buprenorphine treatment for OUD patients. Selected Organizational Readiness to Change Assessment (ORCA) subscales and the focus groups provided additional assessment tools.
- Only 20.9% of participants indicated high readiness to treat with buprenorphine: 21.2% of attending physicians, 24.3% of residents, and 12.5% of APCs
- Only 3.5% had completed training under the Drug Addiction Treatment Act of 2000
Those deemed “most ready” had higher average scores on the ORCA evidence subscales.
(See the publication for details about methods, data collection, assessment, and data analysis and integration.)
Barriers to ED-initiated Buprenorphine Treatment
Among the study’s key findings was respondents’ lack of readiness to initiate buprenorphine treatment. Cited barriers were “a lack of formal training, limitations on time, limited knowledge of local treatment resources, absence of local protocols and referral networks, and perception or culture that this falls outside the scope and practice of emergency medicine.”
Also cited were concerns about the ability to reliably manage referrals. Participants said that having feedback about patients’ successful follow-up treatment would make it easier for them to initiate ED buprenorphine treatment and referral.
Participants’ quotes on an ORCA subscale were revealing:
Addiction and OUD treatment: “That’s not something that we’re even really taught in medical school and certainly not in our training as emergency physicians.”
// “It’s another amount of paperwork and charting and licensure. Applying for a waiver now to do such a thing is another step.”
Traditional ED care: “I feel like this is particularly vulnerable patient population that we’re just saying: ‘Here’s a sheet. Call some numbers. Good luck.’ That’s the way it feels when I discharge these folks.”
Time pressures: “It’s a matter of limited resources in the emergency department. Every minute that I’m writing a Suboxone prescription is a minute that I’m not with my critically ill patient.”
Protocols: “If some of this can be evidence-based and we can cognitively offload, and we can have a system for doing this, that would be easier.”
Assessing patient’s readiness for therapy: “I don’t think that [assessing patients’ readiness for therapy] is a skill that we’re necessarily being trained for right now.”
§ § §
Facilitators to ED-initiated Buprenorphine
The team identified several key facilitators—steps that would increase the likelihood that ED staff would initiate treatment. They included receiving education and training, having local departmental protocols available, and receiving feedback on patient experiences and gaps in quality of care. Also mentioned was better communication within stakeholder groups.
“Together,” the authors wrote, “these data are critical for guiding future implementation efforts to ensure that more patients with OUD receive potentially life-saving treatment with buprenorphine when seen in the ED.”
Five Key Strategies for Promoting Buprenorphine Initiation in the ED
In what may be the most valuable section of the study, in terms of practical application, the team summarized promotion strategies.
- Stress the end benefit to patients
Clinicians were most interested in making changes if they believed it would improve their patients’ outcomes.
- Stress the delivery of new knowledge
The team “identified unique enthusiasm among residents and the potential for ‘teaching up,’ in which practice change (eg, point of care ultrasonography) is driven by the delivery of new knowledge in medical and graduate curriculums.” Students, residents, and recent graduates with unique expertise can share their expertise with more established clinicians who want to keep up with evolving or novel clinical practices.
- Provide feedback on how many patients with OUD began treatment in the ED and were linked to ongoing care
As with sepsis care and other examples of ED-based quality improvement initiatives, individual success stories “could be powerful motivators to enhance practice change,” the investigators stressed.
- Provide protocols; their importance “cannot be overstated”
Protocols signify leadership and multi-stakeholder engagement, and “provide clear clinical evidence and guidelines about the goals of ED care of OUD patients,” according to the team.
- Provide training
ED clinicians said that, in addition to resources and personnel to help them identify appropriate patients, they need training. And they need training to strengthen patients’ motivation for treatment, and to facilitate transitions of care.
Study Limitations
The authors cite three limitations of their study:
▬ The possibility of selection bias, recall bias, and social desirability bias (because two of the study’s authors facilitated focus groups and were on the coding team)
▬ The possibility that generalizing the findings to rural or community-based EDs may not be achievable
▬ The fact that although “perspectives and practices are rapidly evolving across these EDs,” because of the opioid epidemic, the study findings are based on one-time assessments
Authors’ Conclusions
Although few ED clinicians had a high level of readiness to begin buprenorphine treatment, many indicated they were willing to learn—if they had the support they needed. Opportunities to promote change “vary across emergency clinician type,” the authors suggested. “Future implementation strategies should consider these factors and tailor interventions accordingly for attending physicians, residents, and APCs.”
§ § §
References
Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and facilitators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. Published 2020 May 1. doi:10.1001/jamanetworkopen.2020.4561
Weiner SG, Baker O, Bernson D, Schuur JD. One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Ann Emerg Med. 2020;75(1):13-17. doi:10.1016/j.annemergmed.2019.04.020
Methadone and buprenorphine reduce risk of death after opioid overdose. News release. National Institutes of Health. June 19, 2018.
Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Ann Intern Med. 2018;169(3):137-145. doi:10.7326/M17-3107.
