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Multicenter Study
. 2023 Apr 3;6(4):e235439.
doi: 10.1001/jamanetworkopen.2023.5439.

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder

Gail D'Onofrio  1   2   3 , E Jennifer Edelman  2 , Kathryn F Hawk  1 , Marek C Chawarski  1   4 , Michael V Pantalon  1 , Patricia H Owens  1 , Shara H Martel  1 , Richard Rothman  5 , Mustapha Saheed  5 , Robert P Schwartz  6 , Ethan Cowan  7 , Lynne Richardson  8 , Edwin Salsitz  9 , Michael S Lyons  10   11 , Caroline Freiermuth  10   11 , Christine Wilder  11   12 , Lauren Whiteside  13 , Judith I Tsui  14 , Jared W Klein  14 , Edouard Coupet  1 , Patrick G O'Connor  2 , Abigail G Matthews  15 , Sean M Murphy  16 , Kristen Huntley  17 , David A Fiellin  1   2   3
Affiliations
Multicenter Study

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder

Gail D'Onofrio et al. JAMA Netw Open. .

Abstract

Importance: Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.

Objective: To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.

Design, setting, and participants: This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.

Exposure: A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.

Main outcomes and measures: The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.

Results: A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).

Conclusions and relevance: In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.

Trial registration: ClinicalTrials.gov Identifier: NCT03023930.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Pantalon reported being a cofounder of the Center for Progressive Recovery, which has received Small Business Innovation Research and other funding from the National Institutes of Health (NIH) National Institute on Drug Abuse (NIDA) outside the submitted work. Dr Schwartz reported receiving grants from the NIDA outside the submitted work. Dr Freiermuth reported receiving personal fees from Purdue Pharma outside the submitted work. Dr Whiteside reported receiving grants from the NIDA, Centers for Disease Control and prevention (CDC), and National Institute of Mental Health (NIMH) outside the submitted work. Dr Huntley reported that her spouse has a defined benefit plan from previous employment with Pfizer. Dr Fiellin reported that his wife is an owner of Playbl. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Number of Emergency Department (ED) Visits with Buprenorphine Administered or Prescribed Overall and by Site
Data extracted from electronic health records. aIncludes attending physicians, residents, and advanced practice clinicians.
Figure 2.
Figure 2.. Trial Flowchart for the Baseline Evaluation Period
Figure 3.
Figure 3.. Observational Outcomes in Implementation and Effectiveness of Emergency Department (ED)–Initiated Buprenorphine Strategies
IF indicates implementation facilitation; OUD, opioid use disorder.
Figure 4.
Figure 4.. Effectiveness of Emergency Department (ED)–Initiated Buprenorphine for Opioid Use Disorder (OUD) Treatment
See this image and copyright information in PMC

Comment in

References

    1. Ahmad FB, Rossen LM, Sutton P. Provisional Drug Overdose Death Counts. National Center for Health Statistics; 2021:12.
    1. Vivolo-Kantor AM, Seth P, Gladden RM, 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;67(9):279-285. doi:10.15585/mmwr.mm6709e1 - DOI - PMC - PubMed
    1. Soares WE III, Melnick ER, Nath B, et al. . Emergency department visits for nonfatal opioid overdose during the COVID-19 pandemic across six US health care systems. Ann Emerg Med. 2022;79(2):158-167. doi:10.1016/j.annemergmed.2021.03.013 - DOI - PMC - PubMed
    1. Holland KM, Jones C, Vivolo-Kantor AM, et al. . Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2021;78(4):372-379. doi:10.1001/jamapsychiatry.2020.4402 - DOI - PMC - PubMed
    1. National Academies of Sciences, Engineering, and Medicine . Medications for Opioid Use Disorder Save Lives. National Academies Press; 2019. - PubMed

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