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Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program

Open AccessPublished:August 02, 2021DOI:https://doi.org/10.1016/j.annemergmed.2021.05.024

      Study objective

      We retrospectively evaluated the implementation of low-threshold emergency department (ED) buprenorphine treatment at 52 hospitals participating in the CA Bridge Program using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

      Methods

      The CA Bridge model included low-threshold buprenorphine, connection to outpatient care, and harm reduction. Implementation began in March 2019. Participating hospitals reported aggregated clinical data monthly after program initiation. Outcomes included identification of opioid use disorder, buprenorphine administration, and linkage to outpatient addiction treatment. Multivariable models assessed associations between hospital location (rural versus urban) and teaching status (clinical teaching hospital versus community hospital) and outcomes in adopting the CA Bridge Program.

      Results

      Reach: A diverse and geographically distributed group of 52 California hospitals were enrolled in 2 phases (March and August 2019); 12 (23%) were rural and 13 (25%) were teaching hospitals. Effectiveness: Over a 14-month implementation period, 12,009 opioid use disorder patient encounters were identified, including 7,179 (59.7%) where buprenorphine was administered and 4,818 (40.1%) where follow-up visits were attended. Adoption: In multivariable analysis, adoption did not differ significantly between rural and urban or teaching and nonteaching hospitals. Implementation: By program completion, all 52 (100%) hospitals treated opioid use disorder with buprenorphine; 45 (86.5%) administered buprenorphine after naloxone reversal; 41 (84.6%) offered buprenorphine for inpatients; 48 (92.3%) initiated buprenorphine in pregnant women; and 29 (55.8%) offered take-home naloxone. Maintenance: At 8-month follow-up, all 52 sites reported continued buprenorphine treatment.

      Conclusion

      Low-threshold ED buprenorphine treatment implemented with a harm reduction approach and active navigation to outpatient addiction treatment was successful in achieving buprenorphine treatment for opioid use disorder in diverse California communities.
      SEE EDITORIAL, P. 773.

      Introduction

      Emergency departments (EDs) across the United States are at the center of the national surge in opioid-related mortality.
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      Missed opportunities to save lives-treatments for opioid use disorder after overdose.
      What is already known on this topic
      Initiation of buprenorphine in the emergency department (ED) can lead to long-term recovery and reduce death from opioid overdose.
      What question this study addressed
      Can low-threshold initiation of buprenorphine be implemented in diverse ED settings across an entire state?
      What this study adds to our knowledge
      This implementation study across 52 EDs in California showed that low-dose buprenorphine with treatment navigation was largely adopted and maintained for at least 9 months.
      How this is relevant to clinical practice
      Low-threshold buprenorphine treatment from the ED for patients with opioid use disorder can be implemented on a statewide scale.
      The convergence of the COVID-19 pandemic and the opioid crisis has only increased the impact of opioid use disorder on EDs.
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      , At the same time, consumption of high-potency synthetic opioids (eg, fentanyl) increased dramatically in western states, including California, with some communities observing 70% increases in opioid overdose deaths in 2020 versus 2018.
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      EDs frequently care for people with opioid use disorder; however, until recently, they were neither expected nor funded to provide access to medication for opioid use disorder. Initiatives to increase treatment of opioid use disorder were almost exclusively focused on ambulatory settings and specialty addiction centers. However, with this approach, less than 20% of patients receive medication treatment for opioid use disorder,
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      A robust, single-site randomized control trial demonstrated the effectiveness of initiating buprenorphine treatment in the ED (ED buprenorphine) for retaining patients in treatment.
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      Based on these limited but promising data, the rollout of federally supported State Opioid Response Grants through the Substance Abuse and Mental Health Services Administration spurred a rapid and large-scale investment in the implementation of ED buprenorphine in multiple states across the country. The largest of these programs is CA Bridge, which, from 2018 to 2020, led an implementation of low-threshold ED buprenorphine treatment at 52 hospitals in California.
      California to receive $210 million for State Opioid Response over 2 years. California MAT Expansion Project.
      Herein, we describe and evaluate CA Bridge implementation across the geographically and culturally diverse state of California. Lessons learned from CA Bridge may provide urgently needed guidance to ongoing national efforts to integrate EDs into the response to the opioid crisis.

      Methods

       Study Design

      We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to evaluate the overall public health impact of CA Bridge (Table 1). This framework provides a pragmatic approach to evaluate the implementation and scalability of public health interventions.
      • Glasgow R.E.
      • Vogt T.M.
      • Boles S.M.
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      The RE-AIM framework is especially useful in assessing the implementation of complex interventions, such as CA Bridge, for which evaluation is not feasible through typically rigid efficacy studies. The RE-AIM dimensions include: reach (success in reaching the target population), effectiveness (achievement of intended outcomes), adoption (uptake across settings), implementation (consistency and adaptation of the intervention across settings), and maintenance (ongoing implementation of the intervention over time).
      Table 1CA Bridge implementation evaluation using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.
      DimensionOutcomesData Sources
      Reach

      How well did CA Bridge reach the target population?
      Characteristics of hospitals participating in CA BridgeOSHPD data
      Data from the California OSHPD. OSHPD data were not available for 1 hospital (n=51).


      CDPH overdose surveillance data
      2018 Opioid Overdose Surveillance data from the CDPH.


      Applications to CA Bridge
      Hospital-reported metrics from applications to the CA Bridge Program.
      Effectiveness

      How well did CA Bridge achieve intended outcomes?
      Number of patients with opioid use disorder identified

      Number of identified patients who were administered or prescribed buprenorphine

      Number of identified patients who attended follow-up visit
      Hospital aggregate data
      Hospital-reported aggregate numbers of patients identified and treated, reported monthly to the CA Bridge Program.
      Adoption

      What setting characteristics impacted CA Bridge implementation?
      Impact of hospital and county baseline characteristics on patients treatedOSHPD data
      Data from the California OSHPD. OSHPD data were not available for 1 hospital (n=51).


      CDPH overdose surveillance data
      2018 Opioid Overdose Surveillance data from the CDPH.


      Applications to CA Bridge
      Hospital-reported metrics from applications to the CA Bridge Program.


      Hospital aggregate data
      Hospital-reported aggregate numbers of patients identified and treated, reported monthly to the CA Bridge Program.
      Implementation

      Were CA Bridge components implemented as intended?
      Providers completing X-waiver training

      Proportion of hospitals offering buprenorphine in ED, inpatient, postoverdose, in pregnant patients

      Proportion of hospitals offering naloxone

      Proportion of hospitals collaborating with local partner organizations

      Change in monthly patients identified, treated, including during COVID-19

      Perceived impact of telehealth during COVID-19
      Applications to CA Bridge
      Hospital-reported metrics from applications to the CA Bridge Program.


      Hospital-reported grant outcomes
      Grant deliverable outcomes reported by hospitals to CA Bridge at program completion.


      Survey of substance use navigators on telehealth impact
      Survey sent to substance use navigators in May 2020 on impact of telehealth on CA Bridge Program.
      Maintenance

      Has the CA Bridge intervention been maintained over time?
      Hospital report of plans to continue treating with buprenorphine, continue substance use navigator positionHospital aggregate data
      Hospital-reported aggregate numbers of patients identified and treated, reported monthly to the CA Bridge Program.


      Hospital-reported grant outcomes
      Grant deliverable outcomes reported by hospitals to CA Bridge at program completion.
      CDPH, California Department of Public Health; OSHPD, Office of Statewide Health Planning and Development.
      Data from the California OSHPD. OSHPD data were not available for 1 hospital (n=51).
      2018 Opioid Overdose Surveillance data from the CDPH.
      Hospital-reported metrics from applications to the CA Bridge Program.
      § Hospital-reported aggregate numbers of patients identified and treated, reported monthly to the CA Bridge Program.
      | Grant deliverable outcomes reported by hospitals to CA Bridge at program completion.
      Survey sent to substance use navigators in May 2020 on impact of telehealth on CA Bridge Program.

       Setting

      A request for applications was opened to all 320 acute care hospitals in California with EDs in November of 2018. Seventy-eight hospitals applied and were screened by a selection committee. Fifty-two hospitals were selected based on perceived need and readiness to implement buprenorphine for opioid use disorder. Criteria included hospital type (public, nonprofit, for-profit, etc), proportion of patients insured through Medicaid, community race and ethnicity proportions, county overdose rate, and capacity to offer buprenorphine rapidly across the hospital. To ensure rural hospital representation in the cohort, 12 selections were dedicated to hospitals designated as rural by the California Office of State Health Planning and Development. All hospitals were required to have an ED clinician champion, an outpatient provider able to receive patients on buprenorphine, and a letter of support from hospital leadership. As the intervention was based in the ED and nearly all admitted patients treated for opioid use disorder start their hospital encounter in the ED, CA Bridge was considered an ED-based program with natural carryover and impact on patient care to other hospital inpatient units. Hospital-level implementation proceeded in 2 cohorts, the first initiating in March and the second in August of 2019; all direct-to-hospital funding concluded by July of 2020 (Figure E1, available at http://www.annemergmed.com).

       Treatment Model

      The CA Bridge model features a low-threshold buprenorphine treatment approach, active patient navigation from ED care to outpatient addiction treatment, and harm reduction interventions in line with an overdose education and naloxone distribution methodology.
      • Mueller S.R.
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      • Calcaterra S.L.
      • et al.
      A review of opioid overdose prevention and naloxone prescribing: implications for translating community programming into clinical practice.
      The low-threshold buprenorphine approach differs from more traditional treatment guidelines: same-day treatment is provided on demand, counseling is encouraged but not required, and complete abstinence is not expected.
      • Winograd R.P.
      • Presnall N.
      • Stringfellow E.
      • et al.
      The case for a medication first approach to the treatment of opioid use disorder.
      ,
      • Jakubowski A.
      • Fox A.
      Defining low-threshold buprenorphine treatment.
      Novel adaptations of the low-threshold approach to the ED setting included recommending placement signs advertising buprenorphine services in waiting areas, buprenorphine treatment in low-acuity areas with no cardiac monitoring, no drug testing requirement, no opioid treatment contracts, and no requirement of specialist consultation. In cases in which diagnoses of opioid use disorder or opioid withdrawal were clear, clinicians were not required to document full Diagnostic and Statistical Manual of Mental Disorders criteria for opioid use disorder or Clinical Opioid Withdrawal Scale score for withdrawal.
      American Psychiatric Association
      ,
      • Wesson D.R.
      • Ling W.
      The clinical opiate withdrawal scale (COWS).
      Patients not yet in withdrawal could be discharged with a prescription and guidance for home initiation.
      • Lee J.D.
      • Vocci F.
      • Fiellin D.A.
      Unobserved “home” induction onto buprenorphine.
      Buprenorphine dosing guidelines were flexible—ranging from 4 mg up to 32 mg during the ED visit based on clinical judgment and patient preference.
      • Herring A.A.
      • Perrone J.
      • Nelson L.S.
      Managing opioid withdrawal in the emergency department with buprenorphine.
      ,
      • Walsh S.L.
      • Preston K.L.
      • Stitzer M.L.
      • et al.
      Clinical pharmacology of buprenorphine: ceiling effects at high doses.
      ,
      BUPE: buprenorphine use in the emergency department tool. American College of Emergency Physicians.
      Reinitiation of buprenorphine in the ED was permitted for patients who were unsuccessful in connecting to outpatient care. CA Bridge provided guidelines on how to initiate buprenorphine for pregnant patients and immediately after naloxone reversal of overdose.
      Connection to outpatient care was led by a dedicated substance use navigator stationed in the ED. Substance use navigators were trained to use motivational interviewing, nonstigmatizing language, and a nonjudgmental approach toward drug use consistent with a strength-based harm reduction approach.
      • Regis A.
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      • et al.
      Implementation of strength-based case management for opioid-dependent patients presenting in medical emergency departments: rationale and study design of a randomized trial.
      Substance use navigators were not required to have lived experience with substance use disorders, but it was valued as a strength. Substance use navigators were directed to build strong relationships with outpatient partners and be experts in the local treatment ecosystem. Outpatient treatment options varied across sites and by insurance. Options included hospital-based addiction clinics, primary care clinics, opioid treatment programs, and telehealth opioid treatment programs. Substance use navigators were trained to promote access to treatment by assisting patients in obtaining insurance, arranging follow-up appointments, finding transportation, and addressing other challenges, such as homelessness.
      • Manthey T.J.
      • Knowles B.
      • Asher D.
      • et al.
      Strengths-based practice and motivational interviewing.
      An important aim of CA Bridge implementation was to combine buprenorphine treatment with a harm reduction approach including overdose education and naloxone distribution.
      • Jakubowski A.
      • Fox A.
      Defining low-threshold buprenorphine treatment.
      ,
      • Hawk M.
      • Coulter R.W.S.
      • Egan J.E.
      • et al.
      Harm reduction principles for healthcare settings.
      ,
      • Macias-Konstantopoulos W.
      • Heins A.
      • Sachs C.J.
      • et al.
      Between emergency department visits: the role of harm reduction programs in mitigating the harms associated with injection drug use. Ann Emerg Med.
      Substance use navigators and clinicians were trained to foster a culture of respect and decrease stigma throughout the hospital toward people who use drugs.
      • Clarke D.E.
      • Gonzalez M.
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      • et al.
      The impact of knowledge on attitudes of emergency department staff towards patients with substance related presentations: a quantitative systematic review protocol.
      • Sharma M.
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      • et al.
      Harm reduction in hospitals.
      • Simon R.
      • Snow R.
      • Wakeman S.
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      Abstinence was not a requirement to begin buprenorphine treatment; substance use navigators and clinicians were trained to support any reduction in illicit opioid use. EDs were given guidelines on implementing in-hand naloxone distribution without a prescription. Hospital staff were offered training on how to provide safer drug use kits, sterile syringes, and screening for hepatitis C and HIV. Hospitals were encouraged to partner with local public health agencies and syringe service programs.
      National harm reduction coalition.

       Implementation Facilitation

      CA Bridge provided direct hospital funding and technical assistance to build infrastructure at each hospital. Hospitals joined the program in 1 of 2 cohorts (1 lasting 12 months and 1 lasting 18 months). All selected hospitals received a grant from CA Bridge ranging from $125,000 to $260,000. Hospitals used these funds to hire substance use navigators, support clinician champion time, and train staff. After completion of the implementation facilitation program, hospitals no longer received funding from CA Bridge but were encouraged to continue to participate in trainings, apply for alternative funding sources, and work with hospital leadership to create a sustainability plan for the substance use navigator position.
      Implementation at each hospital was led by a team that included at least one clinician champion and a substance use navigator. Clinician champions received 4 in-person trainings on buprenorphine treatment, harm reduction, and implementation strategies. Champions were expected to train colleagues, overcome administrative barriers, and supervise the substance use navigator. CA Bridge provided technical assistance from expert clinician mentors who performed site visits, held X-waiver trainings, and answered clinical and implementation questions at each of the 4 to 6 hospitals for which they were responsible. Substance use navigator education included 10 trainings focused on care navigation, buprenorphine treatment, motivational interviewing, and implementation strategies. Harm reduction training was developed in collaboration with the National Harm Reduction Coalition.
      National harm reduction coalition.
      Equity-focused trainings on working with people who use drugs were led by Mentoring in Medicine & Science.
      National harm reduction coalition.
      ,
      Mentoring in medicine & science.
      A centralized team of CA Bridge substance use navigator mentors supported substance use navigators through coaching, site visits, phone calls, and the Slack communication platform.
      Hospitals were provided with implementation facilitation materials, including clinical guidelines, patient-facing materials, and guidance on relevant regulations through web resources, pop-up trainings, and one-on-one technical assistance. Further details of treatment guidelines can be found at cabridge.org/resources. COVID-19 forced substantial changes to the technical assistance program, including implementation of online trainings and video-conference-based technical assistance, education on COVID-19-related safety, and development of guidance on telehealth for substance use care navigation.

       Measurements and Outcomes

      Outcomes and data sources for the RE-AIM analysis are summarized in Table 1. Data were collected from California hospitals applying to or participating in the CA Bridge Program from the time of application submission in November 2018 to implementation completion in July 2020 (Figure E1). CA Bridge staff provided training and technical support to hospital staff, who collected and reported data. Each participating hospital maintained a database to store clinical and quality assurance data. These data were then aggregated and deidentified by the hospital staff and reported to CA Bridge each month from May 2019 to June 2020.
      Patient outcomes were reported at the hospital level; these included the numbers of patients who were identified with opioid use disorder, had buprenorphine administered or prescribed, and attended an outpatient addiction treatment visit after the initial encounter. Baseline data were defined as the first month of data reported to the program. Peak (defined as the month with the highest value reported) data were used as a comparison instead of end-of-program data due to the disruptions from COVID-19 pandemic.
      Although individual patients could have multiple encounters across months, monthly totals for each outcome represented unique patients. Additionally, outcomes assessed for patients identified with opioid use disorder were independent of all others. For example, a patient with opioid use disorder who was identified may have had a follow-up visit but not have had buprenorphine administered. The buprenorphine administered/prescribed variable was defined as the greater value of the total number of buprenorphine administrations or prescriptions for a given month, since these categories were not mutually exclusive. Each patient’s follow-up visit was counted only once per index encounter that month. Some hospitals had relationships with outpatient clinics that allowed them to access data after hospital discharge, while others relied on substance use navigator phone calls to patients to confirm linkage to opioid use disorder care. Patients who were unable to be reached by phone or whose medical records were unavailable were presumed to have not attended follow-up.
      Hospital baseline characteristics were determined from applications to the program (including baseline buprenorphine administration and number of X-waivered providers), data from the California Office of Statewide Health Planning and Development (rural or nonrural classification, teaching or nonteaching classification, 2018 ED volume), and data from the California Department of Public Health (2018 county overdose rates). CA Bridge support, including funding amount and months of program participation, were extracted from program records. Implementation and maintenance outcomes were extracted from each hospital’s contract deliverable report.
      In May 2020, after the onset of the COVID-19 pandemic, an online survey was administered to substance use navigators from each CA Bridge hospital in order to understand the impact of COVID-19 and the shift to telehealth. Survey respondents received a $15 gift card for participation in the survey.

       Analysis

      Summary and descriptive statistics were performed for hospital implementation benchmarks, patient outcomes, and survey results. CA Bridge sites were mapped graphically onto an image of the state with hospital and county characteristics. Outcomes were plotted by month to observe trends. Bar plots were developed with baseline and peak values of buprenorphine administered/prescribed for each hospital. Average rates of change of each outcome were compared separately for hospitals by rural status and teaching classification. Data for each outcome were overdispersed (greater variance than the mean), necessitating the use of negative binomial regression instead of the traditional Poisson model. Two negative binomial models were used to estimate differences in rates between rural and nonrural hospitals and teaching and nonteaching hospitals. Each multivariable model was adjusted for confounders determined a priori, which included hospital funding amount, buprenorphine on formulary at baseline, ED volume in 2018, and county overdose death rate in 2018; an offset of log time (months after initiation of the CA Bridge Program) was also included. Analyses were conducted using SAS software version 9.4 and SPSS software version 25.1. This investigation was approved by the Public Health Institute Institutional Review Board and the California Health and Human Services Agency Committee for the Protection of Human Subjects.

      Results

       Reach

      CA Bridge hospitals were present in all 10 of California’s 2020 Census regions (Figure 1).
      Census 2020 regions. State of California.
      Participating CA Bridge sites included 12 (23%) rural and 13 (25%) teaching hospitals (Table 2). Participating hospitals had variable patient populations by insurance status and race (Figure E2, available at http://www.annemergmed.com).
      Figure thumbnail gr1
      Figure 1Characteristics and geographic locations of CA Bridge hospitals. ∗Data from the California Office of Statewide Health Planning and Development (OSHPD). OSHPD data were not available from 1 hospital (n=51). Rural and hospital type classification are independent, not mutually exclusive, and defined as per OSHPD. 2018 Opioid Overdose Surveillance data from the California Department of Public Health (CDPH). Rate is deaths per 100,000.
      Table 2CA Bridge reach outcomes: comparison of participating and nonparticipating hospitals.
      Hospital CharacteristicsParticipating Programs (n=52)Nonparticipating Programs (n=26)
      Geographic distribution, n (%)
      Northern California21 (40.4)19 (73.1)
       Central California11 (21.2)2 (7.7)
       Southern California20 (38.5)5 (19.2)
      Hospital type,
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      n (%)
       City or county10 (19.2)2 (7.7)
       District8 (15.4)2 (7.7)
       For-profit5 (9.6)3 (11.5)
       Nonprofit24 (46.2)15 (57.7)
       University of California4 (7.7)0
      Hospital classification,
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      n (%)
       Rural12 (23)4 (15.4)
       Teaching13 (25)0
      County opioid overdose death rate, median (IQR)
       Annual opioid overdose deaths per 100,000
      2018 Opioid Overdose Surveillance data from the California Department of Public Health. Rate is deaths per 100,000.
      4.8 (4.4-8.0)7.7 (2.3-19.1)
      ED volume,
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      median (IQR)
       ED encounters53,488 (34,559-79,306)34,255 (7,127-75,265)
      Percent of all ED encounters by patient demographics,
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      median (IQR)
       Male40.8 (38.2-43.7)46.2 (41.2-53.5)
       Age, %, years
      0-1920.117.7
      20-3930.828.6
      40-5926.125.0
      60+22.829.9
       Race/ethnicity
      White54.8 (28.6-71.4)68.9 (16.0-94.0)
      Black8.0 (2.9-16.3)3.5 (0.9-52.2)
      Other11.2 (3.8-24.1)11.5 (0.8-51.7)
      Hispanic/Latinx29.1 (15.8-40.5)22.0 (3.7-79.8)
      Percent of ED encounters by expected payor,
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      median % (IQR)
       Medicaid or self-pay/uninsured52.6 (42.2-61.9)44.3 (3.4-79.3)
       Medicare14.2 (11.1-20.3)26.4 (17.7-53.2)
       Private13.2 (8.55-17.1)22.25 (9.0-56.8)
      Baseline services,
      Hospital-reported metrics from applications to the CA Bridge Program.
      n (%)
       Treating >1 patient with buprenorphine per week (all hospital units)25 (48.1)16 (30.8)
       At least one X-waivered provider in ED39 (75.0)10 (19.2)
       At least one X-waivered provider outside of ED35 (67.3)14 (27.0)
      IQR, interquartile range.
      Hospitals were selected based on perceived need and readiness to implement buprenorphine for opioid use disorder. Criteria included hospital type, proportion of patients insured through Medicaid, community race/ethnicity proportions, county overdose rate, and capacity to offer buprenorphine rapidly across the hospital.
      Data from the California Office of Statewide Health Planning and Development. Office of Statewide Health Planning and Development data were not available for 1 hospital (n=51). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. Median (IQR) not available for age-related data.
      2018 Opioid Overdose Surveillance data from the California Department of Public Health. Rate is deaths per 100,000.
      Hospital-reported metrics from applications to the CA Bridge Program.

       Effectiveness

      A total of 12,009 patients with opioid use disorder were identified between May 2019 and June 2020. Of these patients, 7,179 (59.8%) were administered buprenorphine (78% in the ED, 22% as inpatients); 5,414 (45.1%) were prescribed buprenorphine; and 4,818 (40.1%) attended at least one opioid use disorder follow-up visit after hospital discharge (Figure 2). At baseline, hospitals reported a mean of 10.5 (95% confidence interval [CI] 6.2 to 14.9) patients identified with opioid use disorder; this increased to 33.1 (95% CI 26.5 to 39.7) at peak. Hospitals reported a baseline of 7.6 (95% CI 4.5 to 10.6) patients administered/prescribed buprenorphine; this increased to 21.4 (95% CI 16.2 to 26.6) at peak.
      Figure thumbnail gr2
      Figure 2CA Bridge patients identified with opioid use disorder, treated with buprenorphine, and linked to outpatient addiction care. ∗A statewide stay-at-home order went into effect on March 19, 2020, in response to the COVID-19 pandemic. Data provided by monthly aggregate reports submitted by participating hospitals between May 2019 and June 2020. Cumulative totals are based on the sum of monthly totals. Patient outcomes were assessed at the encounter level. Monthly totals reflect unique patients for each outcome category; however, patients may have had encounters across multiple months during the timeframe. Outcomes are independent and not mutually exclusive. “Engaged in outpatient addiction treatment” was defined as documentation or patient report of any outpatient addiction care after ED identification of opioid use disorder.

       Adoption

      All hospitals, regardless of urbanicity or teaching status, reported an increase in buprenorphine prescribed/administered (Figure 3). In multivariable analysis, neither urban/rural setting nor teaching status (academic versus nonacademic) was associated with statistically significant differences in patients with opioid use disorder identified, buprenorphine administered, or follow-up visits attended after adjusting for hospital funding amount, buprenorphine on formulary at baseline, ED volume in 2018, and county overdose death rate in 2018.
      Figure thumbnail gr3
      Figure 3Increase in number of buprenorphine prescriptions or administrations from individual hospital baseline to peak, by urbanicity and teaching status. ∗Data provided by monthly aggregate reports submitted by participating hospitals between May 2019 and June 2020. Bar plots show increase in number of baseline buprenorphine use (amount of buprenorphine administered or prescribed in the first month of data collection) to peak use (highest month buprenorphine administered or prescribed). Hospitals are grouped by urbanicity and teaching status. Site-level data is kept confidential and therefore not indicated in this figure. Data from the California Office of Statewide Health Planning and Development (OSHPD). Rural and teaching classification are independent, not mutually exclusive, and defined as per OSHPD. OSHPD data were not available for 1 hospital (n=51).

       Implementation

      By June 2020, 52 hospitals (100.0%) offered buprenorphine starts and 1,647 clinicians attended X-waiver trainings. Forty-five hospitals (86.5%) reported offering buprenorphine after naloxone reversal, 48 (92.3%) offered buprenorphine initiation to pregnant patients, and 44 (84.6%) reported offering buprenorphine to inpatients. Twenty-nine hospitals (55.8%) offered no-prescription, in-hand naloxone distribution (Table 3).
      Table 3CA Bridge implementation and maintenance outcomes
      Hospitals were asked to self-report clinical services and partnerships implemented as of June 2020.
      (N=52).
      Implementationn (%)
      Hospital offers buprenorphine starts
      Required active program by hospital-reported aggregate numbers of patients treated, reported monthly to the CA Bridge Program.
      52 (100.0)
      Signs posted in hospital advertising services
      Report of signs posted in public-facing areas.
      47 (90.4)
      Buprenorphine for opioid use disorder available on inpatient units
      Required order sets, policies and procedures, and staff training in place to identify and treat hospitalized patients with opioid use disorder with buprenorphine.
      45 (86.5)
      ED offers buprenorphine initiation to pregnant women of any gestational age
      Required order sets, policies and procedures, and staff training in place to identify and offer pregnant ED patients with opioid use disorder with buprenorphine initiation without gestational age restrictions.
      49 (94.2)
      Implemented acute pain and perioperative management strategy for patients on buprenorphine maintenance
      Required order sets, policies and procedures, and staff training in place to promote and support buprenorphine continuation through acute pain episodes and the peri-surgical period.
      42 (80.8)
      Postoverdose treatment with buprenorphine
      Required order sets, policies and procedures, and staff training in place to promote and support initiation of buprenorphine after naloxone reversal of opioid overdose.
      45 (86.5)
      No-prescription, in-hand naloxone distribution
      Required order sets, policies and procedures, and staff training in place and naloxone supply acquired to implement direct naloxone distribution to ED patients without a prescription.
      29 (55.8)
      Engagement with local emergency medical services
      Required hospital clinician champion to have at least one meeting with the community partner to discuss improving access to buprenorphine and care coordination for shared patients with opioid use disorder.
      37 (71.2)
      Engagement with law enforcement and jails
      Required hospital clinician champion to have at least one meeting with the community partner to discuss improving access to buprenorphine and care coordination for shared patients with opioid use disorder.
      38 (73.1)
      Engagement with local harm reduction coalition
      Required hospital clinician champion to have at least one meeting with the community partner to discuss improving access to buprenorphine and care coordination for shared patients with opioid use disorder.
      47 (90.4)
      Maintenance: hospital plan if no additional funding is available
      Report of plans for ongoing services if external funding is no longer available.
      Bridge model would continue as normal19 (36.5)
      Bridge model would be scaled back12 (23.1)
      Buprenorphine treatment would still be offered20 (38.5)
      Buprenorphine treatment would no longer be offered1 (1.9)
      Hospitals were asked to self-report clinical services and partnerships implemented as of June 2020.
      Required active program by hospital-reported aggregate numbers of patients treated, reported monthly to the CA Bridge Program.
      Report of signs posted in public-facing areas.
      § Required order sets, policies and procedures, and staff training in place to identify and treat hospitalized patients with opioid use disorder with buprenorphine.
      | Required order sets, policies and procedures, and staff training in place to identify and offer pregnant ED patients with opioid use disorder with buprenorphine initiation without gestational age restrictions.
      Required order sets, policies and procedures, and staff training in place to promote and support buprenorphine continuation through acute pain episodes and the peri-surgical period.
      # Required order sets, policies and procedures, and staff training in place to promote and support initiation of buprenorphine after naloxone reversal of opioid overdose.
      ∗∗ Required order sets, policies and procedures, and staff training in place and naloxone supply acquired to implement direct naloxone distribution to ED patients without a prescription.
      †† Required hospital clinician champion to have at least one meeting with the community partner to discuss improving access to buprenorphine and care coordination for shared patients with opioid use disorder.
      ‡‡ Report of plans for ongoing services if external funding is no longer available.
      At the onset of the COVID-19 stay-at-home order, hospitals initially reported a sudden drop in the identification of patients with opioid use disorder (from 20.5 per month to 14.9 patients per month) in April 2020, but this number recovered (to 23.5 per month) by June 2020. There was a similar drop and subsequent recovery in the number of monthly patients treated with buprenorphine and referred to addiction treatment (Figure 2). Of the 54 substance use navigators who received the survey on COVID-19 and telehealth, 39 responded (72.2%) from 35 hospitals and reported variable telehealth and off-site work policies. Of those respondents, 56.4% reported that COVID-19 negatively impacted their ability to provide face-to-face services, and 43.6% reported using telehealth more since the onset of COVID-19.

       Maintenance

      When initially surveyed, 51 of the 52 hospitals (98.1%) reported that they would continue the CA Bridge model or buprenorphine services even if future funding were not available, although these services might scale back (Table 3). More than one third of hospitals (36.5%) reported that they would continue providing the full array of CA Bridge services, even without future funding. Nine months after program completion, 52 hospitals (100.0%) reported continuation of ED buprenorphine treatment (Table 3).

      Limitations

      There are significant limitations to our study. Hospitals self-selected to join CA Bridge, and without a comparator group that did not participate in CA Bridge, it is not possible to directly isolate the result of the CA Bridge interventions. Our findings may not be generalizable to other California hospitals or to other hospitals in the broader United States. Further prospective studies on comparative strategies for large-scale implementation facilitation are needed. Our findings compare favorably to alternate programs such as the California Hub and Spoke project.
      • Miele G.M.
      • Caton L.
      • Freese T.E.
      • et al.
      Implementation of the hub and spoke model for opioid use disorders in California: rationale, design and anticipated impact.
      ,
      • Darfler K.
      • Sandoval J.
      • Antonini V.P.
      • et al.
      Preliminary results of the evaluation of the California Hub and Spoke Program.
      However, this evaluation was not designed to determine the cost-effectiveness of the CA Bridge interventions, and this remains an important question that deserves further study. Hospital characteristics reported through CA Bridge applications and program implementation results were not independently verified by CA Bridge staff. Data reported by hospitals were monitored by CA Bridge staff for accuracy and consistency, but independent verification of all data was not feasible. As treatment outcome categories were not mutually exclusive or sequential, follow-up rates among patients administered or prescribed buprenorphine could not be verified—only follow-up rates for all patients identified. Hospital reports of patients identified with opioid use disorder were based on case finding, not systematic screening. Therefore, selection bias may be present, since patients who self-identified with opioid use disorder or who were otherwise identified with opioid use disorder by ED staff may have been more likely to accept treatment compared to other patients not identified with opioid use disorder. Data reflect patient encounters rather than unique patients across the timeframe of interest, so there may be repeat visits within these data, the frequency of which is unknown. Follow-up rates may be underestimated due to challenges with collecting this information, including lack of reliable contact information for patients, electronic health record limitations, and confidentiality restrictions. This analysis was confined to programmatic data available during the 14 months of implementation; the analysis of patient-level data both during and after the study period may lead to different outcomes and inferences.

      Discussion

      Fifty-two hospitals dispersed over a large geographic region with substantial cultural, economic, and health system diversity rapidly and successfully implemented ED buprenorphine programs with the support of CA Bridge implementation facilitation. Over a 14-month period, more than 12,000 patients were identified with opioid use disorder, with over 7,000 receiving buprenorphine and 5,000 attending follow-up visits for opioid use disorder treatment. These numbers of treated patients greatly exceed any previously described hospital-based initiative to improve care of patients with opioid use disorder. Remarkably, these achievements occurred amid the disruption caused by the concurrent COVID-19 pandemic and increasing consumption of high-potency synthetic opioids (eg, fentanyl).
      • Shover C.L.
      • Falasinnu T.O.
      • Dwyer C.L.
      • et al.
      Steep increases in fentanyl-related mortality west of the Mississippi River: recent evidence from county and state surveillance.
      All hospitals continued ED buprenorphine after the implementation facilitation period. These findings add substantial evidence to support national efforts to increase adoption of buprenorphine for opioid use disorder as a standard of care in all EDs.
      Addressing the opioid overdose epidemic in the emergency department. Centers for Disease Control and Prevention.
      ,
      A notable early finding in our evaluation was the robust response by hospitals expressing the desire to implement ED buprenorphine treatment. Contrary to commonly held beliefs that acute care staff are not interested in addiction treatment, 78 hospitals with significant variation in ED volume, urbanicity, racial/ethnic demographics, and payor mix applied to CA Bridge.
      • Hawk K.F.
      • D’Onofrio G.
      • Chawarski M.C.
      • et al.
      Barriers and facilitators to clinician readiness to provide emergency department–initiated buprenorphine.
      ,
      • Martin A.
      • Mitchell A.
      • Wakeman S.
      • et al.
      Emergency department treatment of opioid addiction: an opportunity to lead.
      ,
      2017 ACEP emergency physician poll: opioid patients in the emergency department. American College of Emergency Physicians.
      The program was implemented not just by urban academic hospitals but also among rural (23%) and nonteaching hospitals (75%), advancing findings from prior studies showing successful community hospital implementation.
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      ,
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • et al.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      Although 48% of hospitals reported treating patients with buprenorphine at baseline, the relatively low rates of buprenorphine administration in the first months of data reporting indicate that at the majority of sites, there was very limited ED buprenorphine treatment before entry into CA Bridge. After program implementation, the high volume of patients identified, treatment in multiple hospital settings, and large number of clinicians participating in X-waiver training suggest implementation was not driven by a small number of clinician champions alone. The continuation of all CA Bridge sites throughout COVID-19 suggests institutional commitment to maintain ED buprenorphine despite unforeseen challenges.
      The multicomponent CA Bridge model, including low-threshold ED buprenorphine, connection to outpatient addiction treatment, and promotion of a harm reduction approach, resulted in sustainable institutional change, with all hospitals continuing to treat with buprenorphine 9 months after program completion. A key strategy of the CA Bridge model was to adapt protocols to work within the ED setting by lowering barriers for providers and patients. To increase provider comfort and facilitate care for patients, CA Bridge promoted simple treatment algorithms.
      • Jakubowski A.
      • Fox A.
      Defining low-threshold buprenorphine treatment.
      ,
      • Bhatraju E.P.
      • Grossman E.
      • Tofighi B.
      • et al.
      Public sector low threshold office-based buprenorphine treatment: outcomes at year 7.
      ,
      • Krawczyk N.
      • Buresh M.
      • Gordon M.S.
      • et al.
      Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: addressing a critical care gap.
      Substance use navigators were key to the CA Bridge model, as they were trained in motivational interviewing, strength-based care navigation, and harm reduction.
      • Manthey T.J.
      • Knowles B.
      • Asher D.
      • et al.
      Strengths-based practice and motivational interviewing.
      ,
      • Cheon J.W.
      Best practices in community-based prevention for youth substance reduction: towards strengths-based positive development policy.
      ,
      • Saleebey D.
      The strengths perspective in social work practice: extensions and cautions.
      Additionally, empowering substance use navigators and clinicians to be “changemakers” likely reduced stigma in the hospital and spurred adaptation of the health care system to meet patient needs.
      • Lennox R.
      • Lamarche L.
      • O’Shea T.
      Peer support workers as a bridge: a qualitative study exploring the role of peer support workers in the care of people who use drugs during and after hospitalization.
      Participating in this group effort to streamline treatment, dismantle barriers, and support patients may have motivated engagement in implementation activities.
      • Bassuk E.L.
      • Hanson J.
      • Greene R.N.
      • et al.
      Peer-delivered recovery support services for addictions in the United States: a systematic review.
      We observed strong indications that implementation of the CA Bridge model resulted in effective ED buprenorphine programs, with over 12,000 patients identified. Addiction treatment follow-up was lower (40%) than described by D’Onofrio et al
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      (78%), Edwards et al
      • Edwards F.J.
      • Wicelinski R.
      • Gallagher N.
      • et al.
      Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
      (63%), and Bogan et al
      • Bogan C.
      • Jennings L.
      • Haynes L.
      • et al.
      Implementation of emergency department-initiated buprenorphine for opioid use disorder in a rural southern state.
      (60%) but may be a more realistic expectation for large-scale, low-threshold ED buprenorphine programs.
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • et al.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
      This lower follow-up rate may be partially explained by patient-level challenges that could inhibit linkage and engagement after the ED, such as lack of housing/transportation, structural barriers, and concurrent stimulant use. Many of the CA Bridge sites are rural, community hospitals where structural barriers to follow-up treatment may be greater than observed among urban academic centers. A separate analysis of a subgroup of CA Bridge patients by Kalmin et al
      • Kalmin M.
      • Goodman-Meza D.
      • Anderson E.
      • et al.
      Voting with their feet: social factors linked with treatment for opioid use disorder using same-day buprenorphine delivered in California hospitals. Drug Alcohol Depend.
      found high rates of ED buprenorphine treatment by high-risk patients with housing instability, Medicaid insurance, and methamphetamine use. Thus, facilitating access to ED buprenorphine may be effective to reach the most at-risk patients who struggle to access care from outpatient addiction treatment programs, but additional work is needed to successfully establish these patients in routine care after the ED.
      The maintenance of CA Bridge was tested by the COVID-19 pandemic, but patient engagement proceeded despite widespread disruptions in health care. Closures and decreased intakes to addiction treatment programs exacerbated barriers to care for treatment-seeking patients.
      Coronavirus crisis disrupts treatment for another epidemic: addiction. Bruce G.
      ,
      • Pagano A.
      • Hosakote S.
      • Kapiteni K.
      • et al.
      Impacts of COVID-19 on residential treatment programs for substance use disorder.
      This may have led to patients seeking care in the ED who otherwise would have accessed more traditional addiction treatment. CA Bridge saw substantial decreases in acute care patients with opioid use disorder identified, treated, and linked to care at the onset of the stay-at-home order,
      • Herring A.A.
      • Kalmin M.
      • Speener M.
      • et al.
      Sharp decline in hospital and emergency department initiated buprenorphine for opioid use disorder during COVID-19 state of emergency in California.
      but patient volume returned to pre-COVID-19 rates by June 2020. Substance use navigators and clinicians used telehealth as a countermeasure to ensure ongoing access, which was made possible in part by changes in Drug Enforcement Agency regulation tied to the COVID-19 pandemic.
      • Volkow N.D.
      Collision of the COVID-19 and addiction epidemics.
      COVID-19 information page. U.S. Department of Justice Drug Enforcement Administration.
      Despite the time-limited nature of the CA Bridge funding, all 52 hospitals continued to treat with buprenorphine after the end of CA Bridge funding. CA Bridge was intended to support hospitals during the start-up period with intensive technical assistance and financial support. We anticipate that after the intervention period, costs will be significantly lower. Subsequent to CA Bridge, some hospitals continued their program with limited support from the state of California for the substance use navigator position alone.
      DHCS announces behavioral health pilot project awardees. California MAT Expansion Project.
      Sustainable funding for the substance use navigator position is an ongoing need that may be met by hospital, insurer, or government funding. However, this analysis suggests that an initial investment in implementation facilitation can help hospitals start a buprenorphine program that is sustainable at a lower level of funding after start-up.
      How to pay for it: MAT in the emergency department: FAQ. California Health Care Foundation.
      Medication assisted treatment (MAT) FAQs. American College of Emergency Physicians.
      • Busch S.H.
      • Fiellin D.A.
      • Chawarski M.C.
      • et al.
      Cost-effectiveness of emergency department-initiated treatment for opioid dependence.
      Future clinical directions for the CA Bridge Program will include an expansion of services to treat people who use nonopioid drugs and alcohol. Furthermore, California has funded an additional 154 hospitals to hire substance use navigators.
      • Volkow N.D.
      Collision of the COVID-19 and addiction epidemics.
      CA Bridge hospitals that participated in the original program will serve as models for these new hospitals as they onboard substance use navigators and start ED buprenorphine programs. Future studies will be focused on a more comprehensive description of patients treated, with patient-level demographic and outcomes data. Additional studies are needed to determine which program factors best support identification of all patients with opioid use disorder and predictors of buprenorphine initiation and follow-up. While Bush et al
      • Busch S.H.
      • Fiellin D.A.
      • Chawarski M.C.
      • et al.
      Cost-effectiveness of emergency department-initiated treatment for opioid dependence.
      found significant cost-effectiveness in comparison to screening, brief intervention, and referral to treatment, the cost-effectiveness of large-scale interventions such as CA Bridge is an important area for further study.
      In conclusion, large-scale implementation of low-threshold ED buprenorphine, navigation to outpatient addiction treatment, and a harm reduction approach appears feasible. The CA Bridge approach resulted in rapid increases in opioid use disorder patient identification and treatment at a large, diverse cohort of hospitals.

      Supplementary Data

      Figure thumbnail figs1
      Figure E1Timeline of CA Bridge Program. ∗A statewide stay-at-home order went into effect on March 19, 2020, in response to the COVID-19 pandemic.
      Figure thumbnail figs2
      Figure E2CA Bridge hospitals by race, insurance, and teaching status.∗ BIPOC, Black, Indigenous, and people of color. ∗Data from the California Office of Statewide Health Planning and Development (OSHPD). Teaching classification as defined per OSHPD. Demographic and payor data is based on the percent of 2018 ED encounters and represents all ED encounters, not only CA Bridge encounters. OSHPD data were not available for 1 hospital (n=51). BIPOC coded as aggregate of American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, and Unknown.

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