Emergency Departments — A 24/7/365 Option for Combating the Opioid Crisis

D’Onofrio, Gail; McCormack, Ryan; Hawk, Kathryn

doi:10.1056/nejmp1811988

Cited by 86 publications

(101 citation statements)

References 5 publications

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“…Other biases include the potential delay in reporting and variation across different spatial locations, especially as data is abstracted from cumulative case reports rather than daily case counts. Genomic sequencing is done at a large scale during the outbreak, and we hope that estimates of the transmission dynamics from genomic analysis can be compared to those presented here [26,27]. Whether the drop in cases before the presidential election is influenced by reporting will need to be further investigated.…”

Section: Discussionmentioning

confidence: 99%

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018–2019

Kraemer

Pigott

Hill

et al. 2020

BMC Med

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Background: The 2018-2019 Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces in the Democratic Republic of the Congo (DRC) is the largest ever recorded in the DRC. It has been declared a Public Health Emergency of International Concern. The outbreak emerged in a region of chronic conflict and insecurity, and directed attacks against health care workers may have interfered with disease response activities. Our study characterizes and quantifies the broader conflict dynamics over the course of the outbreak by pairing epidemiological and all available spatial conflict data. Methods: We build a set of conflict variables by mapping the spatial locations of all conflict events and their associated deaths in each of the affected health zones in North Kivu and Ituri, eastern DRC, before and during the outbreak. Using these data, we compare patterns of conflict before and during the outbreak in affected health zones and those not affected. We then test whether conflict is correlated with increased EVD transmission at the health zone level. Findings: The incidence of conflict events per capita is~600 times more likely in Ituri and North Kivu than for the rest of the DRC. We identified 15 time periods of substantial uninterrupted transmission across 11 health zones and a total of 120 bi-weeks. We do not find significant short-term associations between the bi-week reproduction numbers and the number of conflicts. However, we do find that the incidence of conflict per capita was correlated with the incidence of EVD per capita at the health zone level for the entire outbreak (Pearson's r = 0.33, 95% CI 0.05-0.57). In the two provinces, the monthly number of conflict events also increased by a factor of 2.7 in Ebolaaffected health zones (p value < 0.05) compared to 2.0 where no transmission was reported and 1.3 in the rest of the DRC, in the period between February 2019 and July 2019.

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Section: Discussionmentioning

confidence: 99%

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018–2019

Kraemer

Pigott

Hill

et al. 2020

BMC Med

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“…3,4 People with OUD not only seek emergency care in high-acuity situations like overdose and withdrawal, but also for comorbid or general health issues. 5 Given the stigma associated with OUD, the ED may serve as the primary access to health care for this vulnerable patient population. 5,6 Thus, the ED provides a unique opportunity to initiate appropriate treatment for OUD.…”

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confidence: 99%

“…5 Given the stigma associated with OUD, the ED may serve as the primary access to health care for this vulnerable patient population. 5,6 Thus, the ED provides a unique opportunity to initiate appropriate treatment for OUD. [7][8][9] Opioid agonist medications, such as buprenorphine/naloxone (BUP) and methadone, are the current standard of treatment for OUD and have been shown to reduce withdrawal symptoms, craving, relapse, overdose, and mortality (all cause and opioid related).…”

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confidence: 99%

Interrupted Time Series of User‐centered Clinical Decision Support Implementation for Emergency Department–initiated Buprenorphine for Opioid Use Disorder

Holland

Nath

Li³

et al. 2020

Academic Emergency Medicine

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Objectives Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians’ unfamiliarity with this practice and perceptions that it is complicated and time‐consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user‐centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED‐initiated BUP. Methods An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)‐based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED‐initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment. Results Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X‐waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just‐in‐time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2). Conclusion Implementation of user‐centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED‐initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.

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“…Persons with OUD who experience an overdose on injected opioids may end up in the emergency room [14][15][16][17]. This creates an opportunity for change and makes this one potential route of buprenorphine induction.…”

Section: Introductionmentioning

confidence: 99%

Routes of non-traditional entry into buprenorphine treatment programs

Champagne‐Langabeer

Swank

Langabeer

2020

Subst Abuse Treat Prev Policy

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Background: Excessive prescribing, increased potency of opioids, and increased availability of illicit heroin and synthetic analogs such as fentanyl has resulted in an increase of overdose fatalities. Medications for opioid use disorder (MOUD) significantly reduces the risk of overdose when compared with no treatment. Although the use of buprenorphine as an agonist treatment for opioid use disorder (OUD) is growing significantly, barriers remain which can prevent or delay treatment. In this study we examine non-traditional routes which could facilitate entry into buprenorphine treatment programs. Methods: Relevant, original research publications addressing entry into buprenorphine treatment published during the years 1989-2019 were identified through PubMed, PsychInfo, PsychArticles, and Medline databases. We operationalized key terms based on three non-traditional paths: persons that entered treatment via the criminal justice system, following emergencies, and through community outreach. Results: Of 462 screened articles, twenty studies met the inclusion criteria for full review. Most studies were from the last several years, and most (65%) were from the Northeastern region of the United States. Twelve (60%) were studies suggesting that the criminal justice system could be a potentially viable entry route, both pre-release or post-incarceration. The emergency department was also found to be a cost-effective and viable route for screening and identifying individuals with OUD and linking them to buprenorphine treatment. Fewer studies have documented community outreach initiatives involving buprenorphine. Most studies were small sample size (mean = < 200) and 40% were randomized trials. Conclusions: Despite research suggesting that increasing the number of Drug Addiction Treatment Act (DATA) waived physicians who prescribe buprenorphine would help with the opioid treatment gap, little research has been conducted on routes to increase utilization of treatment. In this study, we found evidence that engaging individuals through criminal justice, emergency departments, and community outreach can serve as non-traditional treatment entry points for certain populations. Alternative routes could engage a greater number of people to initiate MOUD treatment.

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Emergency Departments — A 24/7/365 Option for Combating the Opioid Crisis

Cited by 86 publications

References 5 publications

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018–2019

Dynamics of conflict during the Ebola outbreak in the Democratic Republic of the Congo 2018–2019

Interrupted Time Series of User‐centered Clinical Decision Support Implementation for Emergency Department–initiated Buprenorphine for Opioid Use Disorder

Routes of non-traditional entry into buprenorphine treatment programs

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