1. Initiation of Buprenorphine in the Emergency Department
What is the evidence and how does it work?
Continuing Education Credit:
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Teresa Hudson, PharmD, PhD

2. 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:
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Activity Code:

3. Set Up for Using Poll Everywhere
Text to this number: 22333
Text this message: Teresahudson735

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

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

15. 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

16. 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

17. 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

18. 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

19. Assessment Tools DSM-V Diagnosis

20. Assessment Tools - COWS
Wesson and Ling J Psychoactive Drugs 2003

22. https://www. drugabuse

23. 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

24. 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

25. 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

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

27. 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

28. 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

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

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

31. 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

33. Continuing Education Credit:
TEXT:
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