Buprenorphine–naloxone practice and attitudes in 22 Canadian emergency physician groups: a cross-sectional survey

Kestler, Andrew; Kaczorowski, Janusz; Dong, Kathryn; Orkin, Aaron; Daoust, Raoul; Moe, Jessica; Pelt, Kelsey Van; Andolfatto, Gary; Klaiman, Michelle; Yan, Justin; Koh, Justin; Crowder, K.; Webster, Devon; Atkinson, Paul; Savage, David; Stempien, James; Besserer, Floyd; Wale, Jason; Lam, Alice; Scheueremeyer, Frank

doi:10.9778/cmajo.20200190

Cited by 11 publications

(17 citation statements)

References 34 publications

(45 reference statements)

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“…This is the first study to identify barriers and facilitators to implementing opioid safety initiatives (opioid prescribing, initiation of M‐OUD, and naloxone distribution) in VA ED/UCC settings. Similar to research conducted in other settings, 6–9 we have identified barriers to the implementation of ED‐based opioid safety initiatives which include provider perceptions that OUD care is outside of the scope of the ED, lack of education (for both providers and patients), difficulty obtaining follow‐up care, and the stigma associated with substance use disorder diagnoses and treatment. The facilitators to implementing these ED‐based opioid safety initiatives are similar in some ways: culture change to destigmatize caring for patients with substance use disorder, increased education and awareness (for providers and patients), protocolized local pathways for diagnosis, treatment and follow‐up, use of technology, and advocacy from national organizations to reduce regulatory obstacles (e.g., X‐waiver requirement).…”

Section: Discussionmentioning

confidence: 87%

“…Similar to research conducted in other settings, [6][7][8][9] we have iden- This shift in the care journey for patients with OUD will require multidisciplinary approaches to education and training, 19 addressing provider biases and stigma, 20 and using whole health approaches (including complementary and integrative medicine) 21 to change the current treatment paradigm that often focuses on physical ailments and not addressing underlying addiction and mental health concerns. Currently, educational efforts, in part, focus on regulatory requirements for X-waiver training, 5 national and federal policy statements, [3][4][5] and guidelines for care.…”

Section: Discussionmentioning

confidence: 88%

“…Prior research in community and academic settings has identified some possible reasons why patients may not be prescribed medications for opioid use disorder (M-OUD) or naloxone in the ED. [6][7][8][9] Lack of knowledge and awareness of how M-OUD works clinically and how it should be administered, difficulty with accessing follow-up care, and fears of inappropriate utilization of the ED have been described in the literature. However, little is known about how these barriers and facilitators may differ or be similar for health care personnel providing care to Veterans.…”

Section: Introductionmentioning

confidence: 99%

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Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

Sasson

Dieujuste

Klocko

et al. 2023

Academic Emergency Medicine

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Objectives: Safer opioid prescribing patterns, naloxone distribution, and medications for opioid use disorder (M-OUD) are an important part of decreasing opioid-related adverse events. Veterans are more likely to experience these adverse events compared to the general population. Despite treatment guidelines and ED-based opioid safety programs implemented throughout Veterans Affairs (VA) Medical Centers, many Veterans with OUD do not receive these harm reduction interventions. Prior research in other health care settings has identified barriers to M-OUD initiation and naloxone distribution; however, little is known about how this may be similar or different for health care professionals in VA ED and urgent care centers. Methods:We conducted qualitative interviews with VA health care professionals and staff using a semistructured interview guide. We analyzed the data addressing barriers and facilitators to M-OUD treatment in the ED and naloxone distribution using descriptive matrix analysis, followed by team consensus. Results:We interviewed 19 VA staff in various roles. Respondent concerns and considerations regarding the initiation of M-OUD in the ED included M-OUD initiation falling outside of ED's scope of providing acute treatment, lack of VA-approved M-OUD protocols and follow-up procedures, staffing concerns, and educational gaps.Respondents reported that naloxone was important but lacked clarity on who should prescribe it. Some respondents stated that an automated system to prescribe naloxone would be helpful, and others felt that it would not offer needed support and education to patients. Some respondents reported that naloxone would not address opioid misuse, which other respondents felt was a belief due to stigma around substance use and lack of education about treatment options.

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Section: Discussionmentioning

confidence: 87%

Section: Discussionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 99%

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Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

Sasson

Dieujuste

Klocko

et al. 2023

Academic Emergency Medicine

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“…We conducted a nationwide paper and electronic survey of physicians at rural and urban EDs in 6 provinces from December 1, 2018 to November 30, 2019. We previously published full survey methodology [ 8 ], in accordance with the CHERRIES reporting checklist ( https://www.equator-network.org ). The questionnaire in English and French included items adapted from previously validated Likert scale questions on attitudes, as well as questions on individual and site-specific characteristics (questionnaire: S1 Appendix ).…”

Section: Methodsmentioning

confidence: 99%

“…Because engaging patients in addictions treatment is challenging, ED providers do not capitalize on every opportunity to initiate BUP. Although two-thirds of emergency physicians are willing to initiate BUP, only one-quarter report doing so at least once a month [ 8 ]. While US-based research has identified relevant individual- and site-level predictors of BUP initiation in the ED [ 9 , 10 ], Canadian data are lacking.…”

Section: Introductionmentioning

confidence: 99%

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

MacKinnon,

Lane,

Scheuermeyer

et al. 2024

PLoS ONE

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Objective To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs. Methods We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence. Results We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup. Conclusions Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

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Physician Reluctance to Intervene in Addiction

Campopiano von Klimo,

Nolan,

Corbin

et al. 2024

JAMA Netw Open

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ImportanceThe overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.ObjectiveTo describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.Data SourcesA literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.Study SelectionPublications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.Data Extraction and SynthesisTwo reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.Main Outcomes and MeasuresThe primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.ResultsA total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.Conclusions and RelevanceIn this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

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Buprenorphine–naloxone practice and attitudes in 22 Canadian emergency physician groups: a cross-sectional survey

Cited by 11 publications

References 34 publications

Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

Barriers and facilitators to implementing medications for opioid use disorder and naloxone distribution in Veterans Affairs emergency departments

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

Physician Reluctance to Intervene in Addiction

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