Initiation of Buprenorphine in the Emergency Department What is the evidence and how does it work? Continuing Education Credit: TEXT: 501-406-0076   Activity Code: 31374-24581 Teresa Hudson, PharmD, PhD

Continuing Education Credit: Disclosures Dr. Hudson has a subcontract with the Arkansas Department of Health to provide academic detailing re: buprenorphine in the emergency department. Continuing Education Credit: TEXT: 501-406-0076   Activity Code: 31374-24581

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The Objectives: After completing this one hour presentation the participants will: Be able to discuss the evidence for the effectiveness of buprenorphine in the ED on treatment engagement for patients with opioid use disorder Be familiar with assessment tools for establishing opioid use disorder and opioid withdrawal Understand the process of buprenorphine initiation in the emergency department.

The Evidence Buprenorphine for treatment of OUD Reduces mortality Haley et al JSAT 2019 Reduces hospital readmission & use of ED Moreno et al J Addict Med 2019 Lo-Ciganic et al Addiction 2016

The Evidence Buprenorphine in the ED One Randomized clinical Trial of Buprenorphine in ED D’Onofrio et al JAMA 2015 D’Onofrio et al JGIMS 2017 Busch et al Addiction 2017 D’Onofrio et al Imple Science 2019 One Retrospective chart review of patients who received buprenorphine in the ED- clinical decision unit Dunkley and colleagues at Grady and Emory Hospitals

The Evidence: One randomized trial – Yale University: Setting: Large urban teaching hospital April 2009 – June 2013 Subjects: included if: Presented to emergency department for any reason Screened positive for OUD UDS positive for opioids N= 329 Outcomes Engagement in treatment at 30 days – based on appts and use of meds Urine drug screen results HIV risk behaviors De’Onofrio et al JAMA 2015 and JGIM 2017

The Evidence – D’Onofrio (cont) Subjects Randomized to: Referral to treatment (given written card about treatment options) Brief intervention and facilitated referral Brief Intervention and Ed-initiated treatment with buprenorphine/naloxone and received appt in primary care within 72 hours Patients were followed for 10 weeks then transferred to community program or clinician for ongoing treatment Patients also offered 2-week detox from buprenorphine

The Evidence – D’Onofrio (cont) Intervention Details: Standard referral to treatment: Received handout from research assistant Contained names, locations and telephone numbers of addiction treatment services in the area. ED allowed them to use the telephone if they wanted to contact treatment during ED visit Brief Intervention: 10-15 minute brief negotiation interview Includes: raising the subject of opioid dependence, provide feedback, enhance motivation and negotiation and advise. RA discussed treatment options with patients IF patient wanted treatment, the RA linked the patient with referral including making sure patients was eligible, had insurance and had transportation. ED Initiated treatment Received Brief Intervention AND buprenorphine if they exhibited moderate to severe opioid withdrawal. Received one dose of buprenorphine in the ED with take home doses sufficient to last until primary care appt in 72 hours Buprenorphine dose: 8mg on day 1, 16mg days 2 and 3. De’Onofrio et al JAMA 2015 and JGIM 2017

The Evidence: (D’Onofrio cont.) Cohort Description: No. (%) of Patients   Overall (n = 329) Referral (n = 104) Brief Intervention (n = 111) Buprenorphine (n = 114) Demographic Characteristics Men 251 (76.3) 81 (77.9) 84 (75.7) 86 (75.4) Race/ethnicity White 248 (75.4) 78 (75.0) 82 (73.9) 88 (77.2) Black 23 (7.0) 7 (6.7) 8 (7.2) 8 (7.0) Hispanic 54 (16.4) 16 (15.4) 21 (18.9) 17 (15.0) Other 4 (1.2) 3 (2.9) 1 (0.9) Age, mean (SD), y 31.4 (10.6) 31.9 (9.7) 31 (9.8) Education High school graduate or equivalent 136 (41.3) 40 (38.5) 51 (45.9) 45 (39.5) Some college 113 (34.4) 33 (31.7) 35 (31.5) ≥College degree 20 (6.1) 9 (8.7) 3 (2.6) Usual employment, past 3 y Full 172 (52.3) 59 (56.7) 57 (51.4) 56 (49.1) Part time 84 (25.5) 26 (25.0) 28 (25.2) 30 (26.3) Married 36 (10.9) 12 (11.5) 10 (9.0) 14 (12.3) No stable living arrangement, past 30 d 30 (9.1) 8 (7.7) 12 (10.5) The Evidence: (D’Onofrio cont.) Health insurance Private/commercial 104 (31.6) 33 (31.7) 33 (29.7) 38 (33.3) Medicare 6 (1.8) 1 (1.0) 3 (2.7) 2 (1.8) Medicaid 142 (43.2) 48 (46.2) 46 (41.4) 48 (42.0) None 71 (21.6) 21 (20.2) 26 (23.4) 24 (21.1) Primary care physician 138 (41.9) 42 (40.4) 50 (43.9) Usual source of care Private physician’s office 92 (27.9) 30 (28.8) 36 (31.6) Clinic 88 (26.7) 26 (25.0) 35 (31.5) 27 (23.7) Emergency department or none 149 (45.3) 50 (45.0) 51 (44.7) De’Onofrio et al JAMA 2015 and JGIM 2017

The Evidence – D’Onofrio (cont) p<0.001 p=0.546 De’Onofrio et al JAMA 2015 and JGIM 2017

The Evidence – D’Onofrio (cont) * *Difference NS

The Evidence – D’Onofrio (cont) * * * * *Difference NS

The Evidence: Cost-Effectiveness? Cost effectiveness analysis by Yale team: Costs for personnel time were estimated ED-initiated buprenorphine : 50 minutes Referral: 15 minutes Brief Intervention Referral : 30 minutes Medication costs: hospital acquisition cost Cost Perspective: willingness to pay by decision maker

The Evidence: Cost-Effectiveness? Note: Costs between the three groups were not significantly different but effectiveness of ED-initiated buprenorphine was more effective in terms of engaging patients in care. Authors indicated incremental cost effectiveness ratios were calculated but these were not provided in the paper Busch et al Addiction 2017

Discharge & refer to treatment How it works Present to ED Seeking Treatment for other problem but OUD suspected Suffer complication of drug use: withdrawal/overdose/other Screen positive on TAPS screening tool Assess OUD: ID OUD based on DSM-5 Criteria Withdrawal: based on Clinical Opioid Withdrawal Scale (COWS) Treat Buprenorphine treatment Algorithm Discharge & refer to treatment Provide guide for using buprenorphine Facilitate treatment appointment Provide Access to buprenorphine until clinic appointment https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/buprenorphine-integration-pathway https://www.chcf.org/wp-content/uploads/2017/12/PDF-EDMATOpioidProtocols.pdf

Assessment Tools - TAPS 2 part screener for substance use Self administered or interviewer administered Part 1: tobacco, alcohol, prescription medication and illicit substances in past year. 5 questions Part 2: assessment for tobacco, alcohol, illicit substance use and prescription medication misuse for past 3 months 9 questions McNeeley et al Ann intern med 2016

Assessment Tools DSM-V Diagnosis https://cchealth.org/aod/pdf/DSM-5%20Diagnosis%20Reference%20Guide.pdf

Assessment Tools - COWS https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/buprenorphine-integration-pathway Wesson and Ling J Psychoactive Drugs 2003

https://www. drugabuse https://www.drugabuse.gov/nidamed-medical-health-professionals/discipline-specific-resources/initiating-buprenorphine-treatment-in-emergency-department/guide-patients-beginning-buprenorphine-treatment-home

The Process/Logistics Two Models: Screen for OUD in ED and initiate buprenorphine in ED if appropriate Did not appear to cost more in D’Onofrio work But: D’Onofrio did not specifically examine costs within ED or impact on work flow/wait time Screen for OUD – if positive transfer to clinical decision unit (CDU) or other short stay unit and initiate buprenorphine Little Cost data from this scenario

The Process/Barriers and Facilitators to Buprenorphine in the ED Survey of physicians in two academic medical centers Web based Small incentive for response ($10) Survey domains: Level of preparation for OUD treatment Barriers and facilitators to buprenorine in the ED Demographic information N=84 (78% response rate) Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.) Respondent Characteristics: Male: 62% Race: White Age: 70% ages 30-49 X waiver: N=18/84 (21%) All were <49 except 1 Other Characteristics Attending: 56% More than 75% time providing clinical care: 73% Ordered buprenorphine in last 3 months: 33% Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.) Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.) Barriers to providing buprenorphine in the ED (top 5) : Patient Social Barriers Lack of patient interest Patient preference for other treatment Comfort counseling patients receiving buprenorphine* Comfort ordering buprenorphine* * - indicates statistically significant different between waivered and non- waivered physicians. This with waivers were more comfortable ordering buprenorphine and counseling patients about buprenorphine Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.) Facilitators to providing buprenorphine in the ED (top 5) Access to treatment after ED Discharge Access to dedicated care coordinator/social worker Order sets for OUD treatment in the EMR Availability of Pharmacist consultation Interesting note: Screening for OUD at triage was lowest facilitator and only was with statistically significant difference based on waiver status. This was rated as more important by physicians who were NOT waivered Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.) Lowenstein et al Am J Emerg Med 2019 epub

The Process/Barriers and Facilitators to Buprenorphine in the ED (Lowenstein cont.)

Support for Buprenorphine in the ED The position of the American College of Medical Toxicology (ACMT), endorsed by the American Academy of Emergency Medicine (AAEM) and the American College of Emergency Physicians (ACEP), is as follows: ACMT supports the administration of buprenorphine in the emergency department (ED) as a bridge to long-term addiction treatment. Furthermore, ACMT supports the administration of buprenorphine to appropriate patients in the ED to treat opioid withdrawal and to reduce the risk of opioid overdose and death following discharge. Wax et al J of Med Tech 2019

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Continuing Education Credit: TEXT: 501-406-0076   Activity Code: 31374-24581