Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Duber, Herbert C.; Barata, Isabel A.; Cioè-Peña, Eric; Liang, Stephen Y.; Ketcham, Eric; Macias‐Konstantopoulos, Wendy; Ryan, Shawn A.; Stavros, Mark; Whiteside, Lauren K.

doi:10.1016/j.annemergmed.2018.04.007

Cited by 88 publications

(89 citation statements)

References 49 publications

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“…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). [10][11][12] A 2015 randomized clinical trial involving 329 ED patients with OUD demonstrated that BUP can be safely initiated in the ED and demonstrated that patients receiving BUP in the ED were twice as likely to remain engaged in formal addiction treatment at 1 month (78% vs. 37%, p < 0.001).…”

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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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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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“…The ED is on the front lines of the opioid overdose epidemic and, as part of the medical safety net and key access point to the health care system, has an essential role in preventing opioid overdose death and facilitating referral to addiction treatment . We found our ED naloxone distribution and community recovery coach consultation program to be overall acceptable to ED providers, had adequate reach and adoption, and was utilized consistently over time without overall significant depreciation 1 year from implementation.…”

Section: Discussionmentioning

confidence: 91%

“…Following an overdose, individuals are at higher risk of death, but some studies have also shown increased enrollment in OUD treatment . Each overdose event and related ED visit, therefore, presents a critical opportunity to prevent not only future overdose death, but also engagement in treatment …”

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confidence: 99%

Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program

Samuels

Baird

Yang

et al. 2018

Academic Emergency Medicine

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“…9 Under the Drug Enforcement Administration's "72-hour rule," buprenorphine can also be administered by nonbuprenorphine physicians for up to 3 days while patients await medication-assisted treatment. 10 Overdose deaths with buprenorphine are less common than with heroin and are most often observed with coingested benzodiazepines. 11 Buprenorphine's ability to…”

Section: Introduction Backgroundmentioning

confidence: 99%

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

Edwards

Wicelinski

Gallagher

et al. 2020

Annals of Emergency Medicine

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Study objective: We assess the feasibility of using our community hospital emergency department (ED) as an immediate portal to medication-assisted treatment for patients in opioid withdrawal. Methods: This was a prospective observational cohort study. In collaboration with an outpatient substance abuse treatment center, we alerted the public through media outlets that individuals could receive immediate buprenorphine treatment for opioid withdrawal in the ED, with rapid referral for medication-assisted treatment. If medication-assisted treatment intake was delayed, patients could return for up to 2 more days for buprenorphine administration to treat their withdrawal symptoms. We measured compliance with initial follow-up and continued treatment engagement at 30 and 90 days. Results: The study was conducted during 12 months. A total of 62 patients were enrolled, evaluated for buprenorphine criteria, and referred for medication-assisted treatment. Fifty subjects were compliant with their first medication-assisted treatment followup visit (81% [95% confidence interval 71% to 91%]), and 43 of these 50 patients were still engaged in medication-assisted treatment at 30 days (86% [95% confidence interval 76% to 96%]), with 33 of the 50 still engaged at 90 days (66% [95% confidence interval 53% to 79%]). We observed no instances of precipitated withdrawal or other adverse reactions in the ED. Conclusion: A substantial number of patients responded to this program and received accelerated engagement in medicationassisted treatment. Such a program is feasible in the community hospital ED and may prevent some individuals from relapsing into high-risk illicit drug use when immediate medication-assisted treatment is not otherwise available. [

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Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Cited by 88 publications

References 49 publications

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

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

Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program

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

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