ED Docs Willing, But Not Ready, to Give Buprenorphine for OUD

Megan Brooks

May 15, 2020

Few emergency department (ED) physicians in the US are ready to prescribe buprenorphine to patients with opioid use disorder (OUD) in this setting, new research shows.  

Nevertheless, many report they are willing to learn how to prescribe the drug, as long as they have sufficient support.

In a survey of ED clinicians from urban academic centers, only 3.5% had completed formal training to prescribe buprenorphine and just 21% felt a "high level" of readiness to offer the medication to patients in need.

The survey is the first installment in Project ED Health, an implementation study funded by the National Institute on Drug Abuse (NIDA) to support strategies for increasing buprenorphine prescribing in the ED.

Dr Kathryn Hawk

This survey provides a "baseline evaluation" of what care EDs are providing to patients with OUD, lead investigator Kathryn Hawk, MD, assistant professor in emergency medicine and attending physician in the ED at Yale New Haven Hospital, New Haven, Connecticut, told Medscape Medical News.

The study was published online May 11 in JAMA Network Open.

An Important Setting

As previously reported by Medscape Medical News, the ED is an important setting for initiating buprenorphine in patients with untreated OUD. ED-initiated buprenorphine therapy and referral to primary care improves opioid-dependent patients' engagement in treatment at 30 days, decreased illicit opioid use, and reduced use of inpatient services.

However, adoption has lagged and readiness to provide buprenorphine varies among ED clinicians.

Hawk and colleagues assessed organizational readiness for ED buprenorphine prescribing among 268 ED physicians and advanced practice clinicians working in the ED at Mount Sinai Hospital in New York City, Johns Hopkins Hospital in Baltimore, Harborview Medical Center in Seattle, and University of Cincinnati Medical Center.

Only 56 (20.9%) of the 268 respondents indicated a "high level" of readiness to initiate buprenorphine and provide referral to ongoing treatment for ED patients with OUD.

One resident physician quoted in the study said: "Trying to suss out which of those patients might be appropriate for initiating some therapy and which aren't is a skill that I don't have. I don't think that it's a skill that we're necessarily being trained for right now."

There was also confusion about required waivers. Only nine of 258 (3.5%) physicians reported completing the Drug Addiction Treatment of 2000 (DATA 2000) "X-waiver" training for buprenorphine. ED clinicians can administer buprenorphine in the ED without the special waiver, but they need clarification around what they can, and can't, do, Hawk said.

Key Barriers

Primary barriers to buprenorphine prescribing in the ED include lack of training and experience, availability of outpatient follow-up, and competing needs and priorities for ED time and resources, the results showed.

Hawk said these barriers can be addressed "by developing tailored treatment protocols, providing multidisciplinary ED staff training, providing feedback to staff about patients who were successfully linked to treatment, and by establishing relationships with specific outpatient referral sites."

In an accompanying commentary, Howard Kim, MD, Northwestern University, Chicago, Illinois, and Elizabeth Samuels, MD, MPH, Brown University, Providence, Rhode Island, note that to truly close gaps in access to medications for OUD, "outpatient buprenorphine treatment capacity must be simultaneously expanded in coordination with efforts to implement ED-based buprenorphine prescribing."

They also write that it's important to note that enthusiasm for starting buprenorphine in the ED was highest among residents and advanced practice clinicians, "suggesting that graduate medical education–focused training efforts would be well received."

However, most undergraduate and graduate medical education programs do not substantively address treatment for OUD, "thus forcing clinicians to obtain extracurricular buprenorphine-specific education, which is a known significant barrier to buprenorphine prescribing," they note.

"Integrating buprenorphine education into medical training nationally would not only better prepare clinicians to successfully care for patients with OUD but also obviate the need for DATA 2000–specific training," Kim and Samuels conclude.

The study was supported by grants from the National Institute on Drug Abuse (NIDA) and the National Institutes of Health (NIH). Hawk, Kim, and Samuels have disclosed no relevant financial relationships. 

JAMA Netw Open. Published online May 11, 2020. Full text, Editorial

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