Emergency department (ED) clinicians could start patients with opioid use disorder (OUD) on the road to life-saving recovery by beginning buprenorphine treatment during an ED visit. But many patients aren’t given a prescription when they leave the ED.
Why is this? Research on treating OUD in the ED has tended to focus on clinician-reported barriers, such as regulatory requirements and lack of training. Little research has examined patients’ thoughts and preferences. If physicians and patients can get on the same wavelength, recovery could start in the ED.
Just published in the journal Academic Emergency Medicine is one of the few studies to examine the ED scene through the eyes of patients with OUD. The study’s objectives are to explore patient perceptions about starting treatment, with the goal of “improving interactions and fostering shared decision-making (SDM) around the important treatment options.” The study’s lead authors, Elizabeth Schoenfeld, MD, Lauren Westafer, DO, and William Soares, MD, are ED physicians at the UMass Chan Medical School – Baystate.
The authors hope that “a better understanding of patients’ perspectives could help improve the quality of patient-centered conversations around the treatment of OUD,” increase initiation of medications for opioid use disorder in the ED, “and increase patient engagement and adherence to treatment following discharge.”
(Direct quotes from patients who served as study participants help clarify issues and emphasize key points. Selected comments are presented below.)
Shared decision-making. In SDM, clinicians do not make decisions for patients. Instead, clinicians and patients share the best available evidence and reach a decision together. (For information about shared decision-making and how to make it work in routine practice, see the citation at the end of this article.)
The research team recruited participants with varied backgrounds and a history of OUD, then conducted semi-structured interviews, concentrating on participants’ ED visits and medication experiences.
Questions about participants’ history of opioid use and OUD treatment were followed by queries about the care of patients with OUD in the ED.
The authors interviewed 26 participants, 7 in person in the ED, and 19 using video conferencing software.
- Almost all participants had visited an ED for an opioid-related issue
- Most had used an unprescribed opioid within the previous two years
- Most had tried both buprenorphine and methadone
- Many were currently being treated with buprenorphine or methadone
And most didn’t know buprenorphine was available in the ED, but were glad to hear that it was.
“. . . that is so good . . . it’s an emergency room, and that’s an emergency.”
“. . . a good way to get somebody on the track to recovery.”
- Buprenorphine and methadone should be offered in the ED (some EDs do start methadone treatment, but that is quite uncommon; currently methadone is available only in opioid treatment programs)
- Clinicians need to understand the various aspects of treatment options, because “one person’s pro is another person’s con”
- Clinicians need to talk with patients about these topics without seeming judgmental
- Medications for OUD (MOUD) should be offered—many patients may not be “ready,” but some may return later for medications
Two issues stand out with buprenorphine. It’s necessary to delay buprenorphine treatment until well after the body has metabolized the most recent dose of a short-acting opioid, such as heroin. Otherwise, “precipitated withdrawal” symptoms can occur. The second issue is that patients cannot “ease into recovery” by using other opioids simultaneously during buprenorphine therapy. Neither issue applies to methadone treatment.
Of the 26 participants, 24 said they had tried buprenorphine, and either liked it or felt it would be effective for some people.
Buprenorphine should be offered in the ED, they said, and they gave three reasons:
- It could save lives
- An ED may provide easier access than a clinic or primary care office, where stigma and logistical barriers may be issues
- Knowing that treatment is available, patients who decline at first might return later
Patients expressed pros and cons:
“You don’t have that high. . . you just feel like everything’s okay”
“The whole switch to [buprenorphine] was super difficult because it takes three or four days with the induction before you start feeling okay”
Methadone has a big advantage over buprenorphine: Patients can continue to use illicit opioids while titrating the methadone dose, “easing in” to recovery. But there’s also a major disadvantage, and that is the need to go to the clinic for the daily dose.
As with buprenorphine, there were favorable views:
“(the clinic has) that control over you. . . I also know people that choose methadone because they need the structure. I think it’s all preference.”
“I’ve had more of a success with methadone. I’ve been sober for a year.”
. . . and unfavorable views:
“. . . one of the worst ideas . . . because you can still use [illicit opioids] with no repercussions . . .”
“. . . [methadone is] very restrictive. You can’t go on vacation, you can’t do all sorts of things. . .”
Are There Alternatives to MOUD?
Very few participants endorsed the alternatives to MOUD—treating with depot naltrexone (Vivitrol) or quitting “cold turkey.” Vivitrol requires a long preliminary period of abstinence, and abrupt quitting isn’t as effective as the other options.
Looking at the choices, it seems that the best solution for a given patient may be . . . the one the patient chooses.
“Just give them a choice. . . It just all depends on your situation and where you are in life, which one’s better for you”
Additional Opinions From Participants
- Clinicians need to avoid seeming judgmental, and they need to be honest about what they don’t know.
- Readiness for treatment is an internal state that others cannot influence, participants said; yet most participants also said treatment should be offered “regardless of a person’s state of readiness.”
- Coordination with outpatient care—a “warm handoff”—would help patients. Also mentioned were psychiatric care, naloxone, peer recovery coaches, lists of outpatient resources, and comfort medications.
- To some people, recovery means abstinence from illicit opioids and medications used to treat OUD. Others allow including treatment medications in the definition. Still others even include “occasional, controlled use of illicit opioids” in the definition of recovery, if the patient is taking treatment medications and holding a job.
- Relapse was part of every patient’s story. The research team found that even for people who had not used illicit opioids in years, reaching the non-use point meant making multiple attempts and trying more than one method of quitting.
- Patients should be offered psychiatric care. Some patients attributed relapses to depression or other psychiatric issues, which they identified as a “major barrier to recovery.”
“The longer you use, the more trauma . . . the harder it is to get over it. You just use to get rid of the trauma. … [then there’s] more trauma . . . It’s an endless cycle . . . ”
Participants supported offering buprenorphine in the ED, and many believed methadone should be offered as well. Treatment should be based on the individual’s needs and circumstances.
The authors’ closing comments touch on the value of patients’ feedback to clinicians. That value is evident in this study.
“ . . . our participants give us insights into how to have meaningful interactions. These results support the use of shared decision-making frameworks in the development of patient-centered interventions to increase the use of MOUD in the ED.”
The authors stressed the importance of patient involvement and shared decision-making, which “puts patients at the center of clinical decisions.”
Figures and Tables—four of each—provide useful details about topics covered in the study.
Schoenfeld EM, Westafer L, Beck SA, et al. “Just give them a choice”: Patients’ perspectives on starting medications for opioid use disorder in the ED [published online ahead of print, 2022 Apr 15]. Acad Emerg Med. 2022;10.1111/acem.14507. doi:10.1111/acem.14507
Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-1367. doi:10.1007/s11606-012-2077-6