Emergency Department Clinicians’ Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study

Abstract

Introduction: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians' attitudes toward the initiation of buprenorphine treatment in the ED. Methods: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital. Results: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up. Conclusion: ED clinicians' perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine. [West J Emerg Med. 2020;21(2)261-271.] decade. 1 As a critical access point for patients with OUD, the ED is well positioned to provide and link patients to OUD treatment. 2 However, current practice in United States EDs for patients seeking treatment for OUD is referral to addiction

A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department

“…Most physicians reported limited or no experience prescribing buprenorphine and expressed feelings of dissatisfaction and frustration with their current interventions for OUD in the ED. Similar perspectives have been reported in a recent survey of ED clinicians in a tertiary center in the United States [ 18 ]. A key difference though was that a minority of the interviewees in that study were in favor of ED-initiated buprenorphine whereas most participants in our study agreed that it should be considered [ 18 ].…”

“…Widespread adoption of new practices takes time and has particularly lagged in the treatment of substance use disorders [ 11 ]. Previous studies have examined attitudes of primary care providers towards prescribing buprenorphine [ 12 – 15 ] as well as those of emergency physicians [ 16 – 18 ]. Yet there is limited literature on attitudes, knowledge and behaviours surrounding OUD and initiating buprenorphine in Canadian EDs [ 16 ].…”

Treating Opioid Withdrawal With Buprenorphine in a Community Hospital Emergency Department: An Outreach Program

“…There is increasing consensus that treating opioid withdrawal in the emergency department (ED) with buprenorphine is superior to symptomatic treatment with a-2 agonists such as clonidine 13 and improves adherence to follow-up regimens. [14][15][16] Another ED treatment modality for opioid withdrawal symptoms involves administering intramuscular methadone. 17 Although effective at symptom reduction, this method has potential disadvantages, including the risk of respiratory depression if the patient ingests opioids or benzodiazepines after discharge from the ED.…”

“…15,26 A recently published article indicated that 80% of emergency physicians believed administering buprenorphine was within their scope of practice. 16 To our knowledge, a program that encourages the public to use a community hospital ED as an immediate portal into medication-assisted treatment has not yet been studied. It is important to establish the feasibility of such a program because many communities experiencing high rates of opioid use disorder exist in more rural areas of the nation, 27,28 such as ours, where there may be substantial waits for patients to consult buprenorphine providers.…”

Impact of Social Distancing on Individuals Who Use Drugs: Considerations for Emergency Department Providers

“…Individual institutions and departmental leadership can best support their clinicians by providing adequate training and resources regarding buprenorphine use, as well as assisting providers in coordination of outpatient linkage to care. 17 …”