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.

Introduction

Opioid use disorder and overdose deaths are rapidly accelerating in the United States, with over 90,000 drug overdose deaths in 2020, largely due to opioids.¹ Opioid use disorder-related emergency department (ED) visits have also increased 100% in the past decade, and there has been increased recognition that ED visits are critical opportunities to initiate evidence-based interventions for opioid use disorder.^2,3 Medications for opioid use disorder, including methadone and buprenorphine, improve a number of outcomes in patients with opioid use disorder, including mortality, measures of physical and mental health, illicit drug use, and retention in treatment.^4,5 Initiation of buprenorphine in a setting as accessible as the ED is particularly promising since it can be administered or prescribed from the ED and continued in general outpatient settings, such as primary care. Randomized controlled trial evidence has demonstrated that ED-initiated buprenorphine doubles rates of treatment engagement at 30 days compared to referral alone and is cost-effective.^6,7 Importantly, the initiation of buprenorphine after a nonfatal overdose is associated with a 38% reduction in mortality at 1 year.⁸ The strength of the evidence has led to recent calls to action by professional and government organizations for EDs to implement opioid use disorder treatment protocols.^9,10

Despite calls to action, there is limited evidence on effective strategies to implement ED-initiated treatment for opioid use disorder and sustain increases in prescribing. Numerous barriers to opioid use disorder treatment have been described, including time, competing demands, lack of knowledge or comfort with opioid use disorder treatment, and lack of protocols or guidance.11, 12, 13 Treatment implementation is further complicated by regulatory requirements, including the need for a DATA 2000 waiver, better known as an X-waiver, required to prescribe buprenorphine for the outpatient setting after discharge. Although federal legislation in April 2021 eliminated the required training to obtain an X-waiver for prescribing buprenorphine to up to 30 patients, it is unclear how this will translate to practice change.¹⁴ Multiple studies in non-ED settings have demonstrated that even among X-waivered providers, the majority do not prescribe buprenorphine.¹⁵ Furthermore, even among X-waivered providers in the acute care setting, other commonly cited obstacles include lack of referral pathways for outpatient treatment and perceived patient barriers, such as lack of housing or social support.^12,16

A critical challenge for widespread adoption is designing scalable strategies that overcome these multilevel barriers to treatment. Prior work from our team demonstrated that a financial incentive was effective in increasing X-waiver credentialing and buprenorphine prescribing in the immediate postperiod, increasing the percentage of X-waivered emergency physicians from 6% to 89%.¹⁷ However, it remained unclear whether this practice would be sustained and universally adopted across ED clinicians. Here, we describe the implementation of a multicomponent ED-based strategy for increasing the identification and treatment of patients with opioid use disorder at 3 urban EDs within a large, academic health system. Our objective was to evaluate the association of these interventions with increasing and sustaining treatment of opioid use disorder in our ED and explore provider-level variation in outcomes.