Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder

Lowenstein, Margaret; Perrone, Jeanmarie; Xiong, Ruiying; Snider, Christopher K.; O’Donnell, Nicole H.; Hermann, Davis; Rosin, Roy; Dees, Julie; McFadden, Rachel; Khatri, Utsha G.; Meisel, Zachary F.; Mitra, Nandita; Delgado, M. Kit

doi:10.1016/j.annemergmed.2021.10.012

Cited by 27 publications

(25 citation statements)

References 44 publications

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“…Given that EMBED increased the proportion of physicians who initiated buprenorphine, EMBED could play a role in changing practice as part of a more comprehensive implementation strategy. For example, multiple recent studies have begun to explore strategies to change behavior, such as nudge interventions,545556 that as part of a more comprehensive strategy could guide clinicians to EMBED resources.…”

Section: Discussionmentioning

confidence: 99%

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

Melnick

Nath

Dziura

et al. 2022

BMJ

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ObjectiveTo determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder.DesignPragmatic cluster randomized controlled trial (EMBED).Setting18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform.Participants599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder.InterventionA user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral.Main outcome measuresRate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.Results1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01).ConclusionsUser centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder.Trial registrationClinicalTrials.govNCT03658642.

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Section: Discussionmentioning

confidence: 99%

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

Melnick

Nath

Dziura

et al. 2022

BMJ

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“…During the study period, the health system implemented a coordinated program to increase buprenorphine treatment for OUD in acute care hospitals and EDs. 11 The University of Pennsylvania Institutional Review Board determined this study was exempt from review. This study followed recommended guidelines for reporting case series.…”

Section: Methodsmentioning

confidence: 99%

“…As part of a quality improvement initiative, cases were referred for review at the discretion of the treating clinician via messaging in the electronic health record (EHR) to a study author (J.P.), a physician with expertise in addiction medicine, emergency medicine, and medical toxicology. 11 All patients initially presented to the ED; however, this study included cases in which buprenorphine was administered either in the ED or inpatient ward within 1 day of admission. For additional context, we extracted EHR data for patients during the study period who were administered buprenorphine but not reported to have concern for PW, although we do not directly compare characteristics between these groups nor intend to estimate PW incidence within this population.…”

Section: Methodsmentioning

confidence: 99%

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Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

et al. 2023

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Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self‐directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.

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“…Study EDs included a large tertiary referral hospital and a level 1 trauma center, which together see over two thousand OUD-related visits annually. The study EDs had previously implemented a robust program of quality improvement for ED-based OUD care, including the availability of guidelines and order sets that incorporate OUD treatment and naloxone prescribing for patients at risk of overdose [29]. Study EDs are also supported by peer recovery specialists well-versed in harm reduction.…”

Section: Study Setting and Time Periodmentioning

confidence: 99%

Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration

et al. 2022

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Background Emergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription. Methods We conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences. Results Of the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge. Conclusions Naloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

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Sustained Implementation of a Multicomponent Strategy to Increase Emergency Department-Initiated Interventions for Opioid Use Disorder

Cited by 27 publications

References 44 publications

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration

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