Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

Hawk, Kathryn; McCormack, Ryan; Edelman, E. Jennifer; Coupet, Edouard; Toledo, Nicolle; Gauthier, Phoebe; Rotrosen, John; Chawarski, Marek C.; Martel, Shara; Owens, Pamela L; Pantalon, Michael V.; O’Connor, Patrick G.; Whiteside, Lauren K.; Cowan, Ethan; Richardson, Lynne D.; Lyons, Michael S.; Rothman, Richard E.; Marsch, Lisa A.; Fiellin, David A.; D’Onofrio, Gail

doi:10.1001/jamanetworkopen.2021.44955

Cited by 29 publications

(16 citation statements)

References 45 publications

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“…Although the ED has been framed as an opportunistic place to provide substance use-related interventions [ 2 , 9 ], participants did not always perceive the ED—and immediately post-overdose—as effective. This has been reported elsewhere [ 19 ] and highlights an opportunity to modify service and resource delivery in ED settings to better meet patients’ needs and improve engagement. Feeling confused, unable to focus, and managing stress following an overdose were described by participants as undermining their ability to engage with services being offered in the ED.…”

Section: Discussionsupporting

confidence: 54%

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

Collins

Baird

Nimaja

et al. 2023

BMC Health Serv Res

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Background Emergency Departments (EDs) have become critical ‘touchpoints’ for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients’ ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients’ experiences with ED staff. Methods This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants’ ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization. Results Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care. Conclusions While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose. Trial registration Clinical trial registration: NCT03684681.

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Section: Discussionsupporting

confidence: 54%

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

Collins

Baird

Nimaja

et al. 2023

BMC Health Serv Res

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“…Indeed, patients with OUD may not perceive the ED as a suitable location for OUD treatment, in part because of prior experiences of stigmatization and discrimination by ED staff, minimization of their medical needs, and inadequate resources for EDs to provide treatment for OUD. 33 However, in our subgroup analysis, there were no meaningful differences in treatment engagement after the ED visit between individuals who were there after an overdose and those who were there for other reasons but who were identified as having had a recent overdose or an OUD-related visit. This suggests that continued engagement after an overdose visit is important but that other patients at high risk should also be considered candidates for a behavioral intervention.…”

Section: Jama Network Open | Substance Use and Addictionmentioning

confidence: 58%

“…It is also unknown whether the overdose visit itself is the most appropriate opportunity for many patients; the psychosocial and physiologic circumstances of the overdose event may actually make it a difficult time to successfully engage patients. Indeed, patients with OUD may not perceive the ED as a suitable location for OUD treatment, in part because of prior experiences of stigmatization and discrimination by ED staff, minimization of their medical needs, and inadequate resources for EDs to provide treatment for OUD . However, in our subgroup analysis, there were no meaningful differences in treatment engagement after the ED visit between individuals who were there after an overdose and those who were there for other reasons but who were identified as having had a recent overdose or an OUD-related visit.…”

Section: Discussionmentioning

confidence: 74%

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose

et al. 2022

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IMPORTANCE Fatal and nonfatal opioid overdoses are at record levels, and emergency department (ED) visits may be an opportune time to intervene. Peer-led models of care are increasingly common; however, little is known about their effectiveness. OBJECTIVE To evaluate the effect of a peer-led behavioral intervention compared with the standard behavioral intervention delivered in the ED on engagement in substance use disorder (SUD) treatment within 30 days after the ED encounter. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial recruited 648 patients from 2 EDs from November 15, 2018, to May 31, 2021. Patients were eligible to participate if they were in the ED for an opioid overdose, receiving treatment related to an opioid use disorder, or identified as having had a recent opioid overdose. INTERVENTIONS Participants were randomly assigned to receive a behavioral intervention from a certified peer recovery specialist (n = 323) or a standard intervention delivered by a hospitalemployed licensed clinical social worker (n = 325). A certified peer recovery specialist was someone with at least 2 years of recovery who completed a 45-hour training program and had 500 hours of supervised work experience. After the ED intervention, the certified peer recovery specialists offered continued contact with participants for up to 90 days. MAIN OUTCOMES AND MEASURESThe primary outcome was receipt of SUD treatment within 30 days of enrollment, assessed with deterministic linkage of statewide administrative databases.Treatment engagement was defined as admission to a formal, publicly licensed SUD treatment program or receipt of office-based medication for opioid use disorder within 30 days of the initial ED visit. RESULTS Among the 648 participants, the mean (SD) age was 36.9 (10.8) years, and most were male (442 [68.2%]) and White (444 [68.5%]). Receipt of SUD treatment occurred for 103 of 323 participants (32%) in the intervention group vs 98 of 325 participants (30%) in the usual care group within 30 days of the ED visit. Among all participants, the most accessed treatments were outpatient medication for opioid use disorder (buprenorphine, 119 [18.4%]; methadone, 44 [6.8%]) and residential treatment (44 [6.8%]). CONCLUSIONS AND RELEVANCEOverall, this study found that a substantial proportion of participants in both groups engaged in SUD treatment within 30 days of the ED visit. An ED-based behavioral intervention is likely effective in promoting treatment engagement, but who delivers the (continued) Key Points Question Can peer-led behavioral interventions in the emergency department for patients who have had a recent opioid overdose increase shortterm treatment engagement after the emergency department visit? Findings In this randomized clinical trial of 648 emergency department patients at high risk of opioid overdose, there was no difference in treatment engagement within 30 days of the visit for participants who received a peer-led intervention vs those who received a standard behavioral intervention by a clin...

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“…Our previously published reports on barriers and facilitators of ED-initiated buprenorphine, including information gleaned from patient perspectives, discovered during our formative evaluation were and are critical to the success of facilitating practice change. These comprehensive strategies, including recruitment of champions, eliciting buy-in from departmental and institutional leadership, establishment of community partners for follow-up care, and protocol development informed by existing staff at all levels tailored to individual sites, are of great value to EDs in the early adoption phase and are associated with increased likelihood of adoption of ED-initiated buprenorphine …”

Section: Discussionmentioning

confidence: 98%

Implementation Facilitation to Promote Emergency Department–Initiated Buprenorphine for Opioid Use Disorder

et al. 2023

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ImportanceEmergency department (ED)–initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.ObjectiveTo evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.Design, Setting, and ParticipantsThis multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.ExposureA 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.Main Outcomes and MeasuresThe primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.ResultsA total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P &lt; .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P &lt; .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).Conclusions and RelevanceIn this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.Trial RegistrationClinicalTrials.gov Identifier: NCT03023930

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Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

Abstract: This qualitative study assesses the experiences and perspectives of individuals with untreated opioid use disorder seen in emergency departments (EDs) in 5 regions of the US.

Cited by 29 publications

References 45 publications

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose

Implementation Facilitation to Promote Emergency Department–Initiated Buprenorphine for Opioid Use Disorder

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