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

      Study objective

      There is strong evidence supporting emergency department (ED)-initiated buprenorphine for opioid use disorder, but less is known about how to implement this practice. Our aim was to describe implementation, maintenance, and provider adoption of a multicomponent strategy for opioid use disorder treatment in 3 urban, academic EDs.

      Methods

      We conducted a retrospective analysis of electronic health record data for adult patients with opioid use disorder-related visits before (March 2017 to November 2018) and after (December 2018 to July 2020) implementation. We describe patient characteristics, clinical treatment, and process measures over time and conducted an interrupted time series analysis using a patient-level multivariable logistic regression model to assess the association of the interventions with buprenorphine use and other outcomes. Finally, we report provider-level variation in prescribing after implementation.

      Results

      There were 2,665 opioid use disorder-related visits during the study period: 28% for overdose, 8% for withdrawal, and 64% for other conditions. Thirteen percent of patients received medications for opioid use disorder during or after their ED visit overall. Following intervention implementation, there were sustained increases in treatment and process measures, with a net increase in total buprenorphine of 20% in the postperiod (95% confidence interval 16% to 23%). In the adjusted patient-level model, there was an immediate increase in the probability of buprenorphine treatment of 24.5% (95% confidence interval 12.1% to 37.0%) with intervention implementation. Seventy percent of providers wrote at least 1 buprenorphine prescription, but provider-level buprenorphine prescribing ranged from 0% to 61% of opioid use disorder-related encounters.

      Conclusion

      A combination of strategies to increase ED-initiated opioid use disorder treatment was associated with sustained increases in treatment and process measures. However, adoption varied widely among providers, suggesting that additional strategies are needed for broader uptake.
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      References

      1. Centers for Disease Control and Prevention. Provisional drug overdose death counts, 2021. Accessed November 20, 2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

        • Vivolo-Kantor A.M.
        • Seth P.
        • Gladden R.M.
        • et al.
        Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017.
        MMWR Morb Mortal Wkly Rep. 2018; : 279-285
        • Kaczorowski J.
        • Bilodeau J.
        • Orkin A.M.
        • et al.
        Emergency department-initiated interventions for patients with opioid use disorder: a systematic review.
        Acad Emerg Med. 2020; 27: 1173-1182
        • Srivastava A.
        • Kahan M.
        • Nader M.
        Primary care management of opioid use disorders: abstinence, methadone, or buprenorphine-naloxone?.
        Can Fam Physician. 2017; 63: 200-205
        • Martin A.
        • Mitchell A.
        • Wakeman S.
        • et al.
        Emergency department treatment of opioid addiction: an opportunity to lead.
        Acad Emerg Med. 2018; 25: 601-604
        • 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.
        JAMA. 2015; 313: 1636-1644
        • Busch S.H.
        • Fiellin D.A.
        • Chawarski M.C.
        • et al.
        Cost-effectiveness of emergency department-initiated treatment for opioid dependence.
        Addiction. 2017; 112: 2002-2010
        • Larochelle M.R.
        • Bernson D.
        • Land T.
        • et al.
        Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.
        Ann Intern Med. 2018; 169: 137-145
        • E-QUAL Network Opioid Initiative
        American College of Emergency Physicians.
        • Office of the Assistant Secretary for Planning and Evaluation
        State and Local Policy Levers for Increasing Treatment and Recovery Capacity to Address the Opioid Epidemic: Final Report.
        US Department of Health and Human Services. 2017;
        • Mackey K.
        • Veazie S.
        • Anderson J.
        • et al.
        Barriers and facilitators to the use of medications for opioid use disorder: a rapid review.
        J Gen Intern Med. 2020; 35: 954-963
        • Lowenstein M.
        • Kilaru A.
        • Perrone J.
        • et al.
        Barriers and facilitators for emergency department initiation of buprenorphine: a physician survey.
        Am J Emerg Med. 2019; 37 (1787–1709)
        • Hawk K.F.
        • D'Onofrio G.
        • Chawarski M.C.
        • et al.
        Barriers and facilitators to clinician readiness to provide emergency department-initiated buprenorphine.
        JAMA Netw Open. 2020; 3e204561
      2. Federal Register. Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. US Department of Health and Human Services; 2021. Document Number 2021–08961. Accessed November 20, 2021. https://www.govinfo.gov/content/pkg/FR-2021-04-28/pdf/2021-08961.pdf

        • Duncan A.
        • Anderman J.
        • Deseran T.
        • et al.
        Monthly patient volumes of buprenorphine-waivered clinicians in the US.
        JAMA Netw Open. 2020; 3e2014045
        • Zuckerman M.
        • Kelly T.
        • Heard K.
        • et al.
        Physician attitudes on buprenorphine induction in the emergency department: results from a multistate survey.
        Clin Toxicol (Phila). 2021; 59: 279-285
        • Foster S.D.
        • Lee K.
        • Edwards C.
        • et al.
        Providing incentive for emergency physician X-waiver training: an evaluation of program success and postintervention buprenorphine prescribing.
        Ann Emerg Med. 2020; 76: 206-214
        • Glasgow R.E.
        • Vogt T.M.
        • Boles S.M.
        Evaluating the public health impact of health promotion interventions: the RE-AIM framework.
        Am J Public Health. 1999; 89: 1322-1327
        • Ogrinc G.
        • Davies L.
        • Goodman D.
        • et al.
        SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.
        BMJ Qual Saf. 2016; 25: 986-992
      3. 2016 Overdoses From Opioids in Philadelphia. Philadelphia Department of Public Health.
      4. DSM-5 Diagnoses and New ICD-10-CM Codes As Ordered in the ICD-10-CM Classification. American Psychiatric Association.
        • Curran G.M.
        • Bauer M.
        • Mittman B.
        • et al.
        Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact.
        Med Care. 2012; 50: 217-226
        • Proctor E.K.
        • Powell B.J.
        • McMillen J.C.
        Implementation strategies: recommendations for specifying and reporting.
        Implement Sci. 2013; 8: 139
        • Fogg B.
        A behavior model for persuasive design. Paper presented at: Proceedings of the 4th International Conference on Persuasive Technology.
        California, USA, ClaremontApril 26-29, 2009 (April 26-29, 2009.)
        • Dopp A.R.
        • Parisi K.E.
        • Munson S.A.
        • et al.
        Integrating implementation and user-centred design strategies to enhance the impact of health services: protocol from a concept mapping study.
        Health Res Policy Syst. 2019; 17: 1-11
        • Powell B.J.
        • Waltz T.J.
        • Chinman M.J.
        • et al.
        A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project.
        Implement Sci. 2015; 10: 1-14
        • Asch D.A.
        • Terwiesch C.
        • Mahoney K.B.
        • et al.
        Insourcing health care innovation.
        N Engl J Med. 2014; 370: 1775
        • Reif S.
        • Braude L.
        • Lyman D.R.
        • et al.
        Peer recovery support for individuals with substance use disorders: assessing the evidence.
        Psychiatr Serv. 2014; 65: 853-861
        • Jack H.E.
        • Oller D.
        • Kelly J.
        • et al.
        Addressing substance use disorder in primary care: the role, integration, and impact of recovery coaches.
        Subst Abus. 2018; 39: 307-314
        • Waye K.M.
        • Goyer J.
        • Dettor D.
        • et al.
        Implementing peer recovery services for overdose prevention in Rhode Island: an examination of two outreach-based approaches.
        Addict Behav. 2019; 89: 85-91
        • Chartash D.
        • Paek H.
        • Dziura J.D.
        • et al.
        Identifying opioid use disorder in the emergency department: multi-system electronic health record-based computable phenotype derivation and validation study.
        JMIR Med Inform. 2019; 7e15794
        • Lee K.C.
        • et al.
        Making workplace civility go viral.
        NEJM Catalyst. 2020; 1
        • Samuels E.A.
        • D'Onofrio G.
        • Huntley K.
        • et al.
        A quality framework for emergency department treatment of opioid use disorder.
        Ann Emerg Med. 2019; 73: 237-247
      5. US Electronic Code of Federal Regulations. Medication Assisted Treatment for Opioid Use Disorders. 2016. 42 CFR Part 8. Accessed 20 November, 2021. https://www.ecfr.gov/#se42.1.8_112

      6. R: a language and environment for statistical computing [computer program]. Austria, Vienna2018
        • Howell B.A.
        • Abel E.A.
        • Park D.
        • et al.
        Validity of incident opioid use disorder (OUD) diagnoses in administrative data: a chart verification study.
        J Gen Intern Med. 2021; 36: 1264-1270
        • Kelly T.
        • Hoppe J.A.
        • Zuckerman M.
        • et al.
        A novel social work approach to emergency department buprenorphine induction and warm hand-off to community providers.
        Am J Emerg Med. 2020; 38: 1286-1290
        • Kaucher K.A.
        • Caruso E.H.
        • Sungar G.
        • et al.
        Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program.
        Am J Emerg Med. 2020; 38: 300-304
        • Edwards F.J.
        • Wicelinski R.
        • Gallagher N.
        • et al.
        Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program.
        Ann Emerg Med. 2020; 75: 49-56
        • Beauchamp G.A.
        • Laubach L.T.
        • Esposito S.B.
        • et al.
        Implementation of a medication for addiction treatment (MAT) and linkage program by leveraging community partnerships and medical toxicology expertise.
        J Med Toxicol. 2021; 17: 176-184
        • Holland W.C.
        • Nath B.
        • Li F.
        • et al.
        Interrupted time series of user-centered clinical decision support implementation for emergency department-initiated buprenorphine for opioid use disorder.
        Acad Emerg Med. 2020; 27: 753-763
        • Hawk K.
        • D'Onofrio G.
        Emergency department screening and interventions for substance use disorders.
        Addict Sci Clin Pract. 2018; 13: 18
        • McGuire A.B.
        • Powell K.G.
        • Treitler P.C.
        • et al.
        Emergency department-based peer support for opioid use disorder: emergent functions and forms.
        J Subst Abuse Treat. 2020; 108: 82-87
        • Halpern S.D.
        • Ubel P.A.
        • Asch D.A.
        Harnessing the power of default options to improve health care.
        N Engl J Med. 2007; 357: 1340-1344
        • Delgado M.K.
        • Shofer F.S.
        • Patel M.S.
        • et al.
        Association between electronic medical record implementation of default opioid prescription quantities and prescribing behavior in two emergency departments.
        J Gen Intern Med. 2018; 33: 409-411
        • Halpern S.D.
        • Loewenstein G.
        • Volpp K.G.
        • et al.
        Default options in advance directives influence how patients set goals for end-of-life care.
        Health Aff (Millwood). 2013; 32: 408-417
        • Follman S.
        • Arora V.M.
        • Lyttle C.
        • et al.
        Naloxone prescriptions among commercially insured individuals at high risk of opioid overdose.
        JAMA Netw Open. 2019; 2e193209
        • Kilaru A.S.
        • Liu M.
        • Gupta R.
        • et al.
        Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal.
        Am J Emerg Med. 2021; 47: 154-157
        • Gerber J.S.
        • Prasad P.A.
        • Fiks A.G.
        • et al.
        Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial.
        JAMA. 2013; 309: 2345-2352
        • Meeker D.
        • Linder J.A.
        • Fox C.R.
        • et al.
        Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.
        JAMA. 2016; 315: 562-570
        • Navathe A.S.
        • Volpp K.G.
        • Bond A.M.
        • et al.
        Assessing the effectiveness of peer comparisons as a way to improve health care quality.
        Health Aff (Millwood). 2020; 39: 852-861
        • Fiscella K.
        • Wakeman S.E.
        • Beletsky L.
        Buprenorphine deregulation and mainstreaming treatment for opioid use disorder: X the X Waiver.
        JAMA Psychiatry. 2019; 76: 229-230
      7. The Mainstreaming Addiction Treatment (MAT) Act. In. 2021-2022 ed2021.