Understanding current practice of opioid use disorder management in emergency departments across Canada: A cross-sectional study

Abstract

Objective Opioid-related deaths are increasing at alarming rates in Canada, with a 34% increase from 2016 to 2017. Patients with opioid use disorder often visit emergency departments (ED), presenting an opportunity to engage patients in treatment. Buprenorphine-naloxone is first-line treatment for opioid use disorder, but current management in the ED is unknown. This study aimed to characterize opioid use disorder management in the ED. Methods We conducted a cross-sectional study of emergency physicians across Canada. A survey was circulated electronically to the Canadian Association of Emergency Physicians members. Participants were asked about their current management practices, satisfaction, and helpfulness of resources. SAS (version 9.4) was used for statistical analysis. We dichotomized Likert-scale responses to approximate relative risk ratios via a log binomial analysis. Results The survey was completed by 179 participants for a response rate of 11.1%; 143 (79.9%) physicians treated patients with opioid use disorder more than once a week. Only 7% (n = 13) of respondents always/often gave buprenorphine in the ED. Referral to an addiction clinic where patients were seen quickly was deemed the most helpful (90.5%, n = 162). Physicians who reported satisfaction with opioid use disorder management were four times more likely to prescribe buprenorphine in the ED or as an outpatient script (RR = 4.41, CI = 2.33–8.33, p < 0.01; RR = 4.51, CI = 2.21–9.22, p < 0.01). Conclusion This study found that buprenorphine is not frequently prescribed in the ED setting, which is incongruent with the 2018 guidelines. Care coordination and on-site support were helpful to ED physicians. Hospitals should use knowledge translation strategies to improve the care of patients with an opioid use disorder.

Buprenorphine–naloxone practice and attitudes in 22 Canadian emergency physician groups: a cross-sectional survey

“…Although many studies have reported on ED-specific or region-based BUP programs, 17,[19][20][21][22] few studies have reported the practice patterns of individual ED physicians. Compared with a 2018 survey that found 7% of Canadian ED physicians prescribed BUP often or always, 28 a greater proportion of our respondents reported prescribing BUP once a month or more. This 2018 study had an 11% response rate and 19% of the †The sum of these percentages is > 100% because at least once per month includes at least once per shift.…”

“…We recruited ED physicians using a group-driven strategy, targeting groups with qualifying physician leads and at least 30 000 annual visits at their largest ED (by group lead report). We developed this strategy to maximize response within participating groups, avoid the low participation rates that often occur in conventional online surveys disseminated to emergency physicians by professional associations, 28 and build on prior ED BUP surveys that had achieved adequate response rates using site-specific strategies. 26,27,29 The goal was to obtain a sample strongly representative of emergency physicians working at selected EDs across Canada, rather than a sample weakly representative of all Canadian emergency physicians.…”

Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study

“…11,19 Previous work has demonstrated a low level of readiness to prescribe BUP to ED patients in both US and Canadian settings. 18,19,21 Among other things, clinicians have called for improved access to incentivized OAT training programs 6,34 and dedicated human resources such as adequately trained staff and access to integrated community addiction resources. 20,35,36 Standardized protocols and care pathways have also been identified as a means to facilitate practice change.…”

“…20 In a recent survey of Canadian physicians, although 79.9% treated patients with OUD more than once per week, only 7% of respondents always/often offered BUP in the ED. 21 In contrast to the United States, once Canadian physicians have completed the required training (if any) as outlined by their provincial or territorial regulatory body, there is no maximum number of patients that can be prescribed BUP per physician. In addition, most provinces only require completion of an online course, and several provinces have instituted phone consultation lines to assist with the management of complex patients.…”

Barriers and attitudes reported by Canadian emergency physicians regarding the initiation of buprenorphine/naloxone in the emergency department for patients with opioid use disorder

“…Despite the initiation of buprenorphine/naloxone in the ED being an evidence-based and guideline-recommended practice, a 2020 survey of Canadian emergency physicians indicates that it is not frequently prescribed [5]. Barriers reported from physicians working in urban centres in the United States included lack of local protocols, time constraints, and arranging appropriate follow-up [6][7][8].…”