Medication for opioid use disorder (MOUD) is the standard evidence-based treatment option for patients with opioid use disorder (OUD). Initiating MOUD in the emergency department (ED) may help patients start the treatment and lead to greater success in sustaining recovery from OUD. Programs have been introduced in EDs to support the initiation of MOUD, but little is known about the implementation facilitators and challenges that impact these programs. The objective of this study was to explore key partners’ perspectives about the facilitators and challenges of implementing and operating an ED-based MOUD program in a large, Midwestern academic medical center.
Methods:
Interviews were conducted in April and May 2019 with physicians, nurses, social workers, pharmacists, and administrators who were involved in implementing the ED MOUD initiation program. Verbatim transcripts were analyzed both deductively and inductively to identify themes related to the facilitators and challenges of program implementation, and suggestions about factors that contributed to program success.
Results:
We found subthemes related to each of these 3 major themes. First, facilitators of program implementation included institutional buy-in, community support, involvement of an interdisciplinary team, availability of ongoing training, and public awareness of the opioid epidemic. Second, program implementation challenges included inadequate staffing and training, complications in treatment linkage, uncertainty in prescribing, unclear workflow, and culture change. Identified success factors for program implementation included provider, community, and patient education, data availability, and provider buy-in.
Conclusion:
Our study results suggest that attention to factors such as buy-in, the need for the right training and education, and establishing key relationships with community organizations can help ED-based MOUD programs fill a critical gap in care for patients with OUD.
LangabeerJRStottsALBobrowBJ, et al. Prevalence and charges of opioid-related visits to U.S. emergency departments. Drug Alcohol Depend. 2021;221:108568. doi:10.1016/j.drugalcdep.2021.108568
3.
SalzmanMJonesCWRafeqRGaughanJHarozR.Epidemiology of opioid-related visits to US Emergency Departments, 1999–2013: a retrospective study from the NHAMCS (National Hospital Ambulatory Medical Care Survey). Am J Emerg Med. 2020;38(1):23-27. doi:10.1016/j.ajem.2019.03.052
4.
DuberHCBarataIACioè-PeñaE, et al. Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med. 2018;72(4):420-431. doi:10.1016/j.annemergmed.2018.04.007
5.
SamuelsEAD’OnofrioGHuntleyK, et al. A quality framework for emergency department treatment of opioid use disorder. Ann Emerg Med. 2019;73(3):237-247. doi:10.1016/j.annemergmed.2018.08.439
6.
WakemanSELarochelleMRAmeliO, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622
7.
BaxleyCBorsariBReavisJV, et al. Effects of buprenorphine on opioid craving in comparison to other medications for opioid use disorder: a systematic review of randomized controlled trials. Addict Behav. 2023;139:107589. doi:10.1016/j.addbeh.2022.107589
8.
Torres-LockhartKELuTYWeimerMBSteinMRCunninghamCO.Clinical management of opioid withdrawal. Addiction. 2022;117(9):2540-2550. doi:10.1111/add.15818
9.
StrangJVolkowNDDegenhardtL, et al. Opioid use disorder. Nat Rev Dis Primers. 2020;6(1):1-28. doi:10.1038/s41572-019-0137-5
10.
CraftWHTeggeANKeithDR, et al. Recovery from opioid use disorder: a 4-year post-clinical trial outcomes study. Drug Alcohol Depend. 2022;234:109389. doi:10.1016/j.drugalcdep.2022.109389
11.
WeissRDPotterJSGriffinML, et al. Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study. Drug Alcohol Depend. 2015;150:112-119. doi:10.1016/j.drugalcdep.2015.02.030
12.
ZhuYEvansEAMooneyLJ, et al. Correlates of long-term opioid abstinence after randomization to methadone versus buprenorphine/naloxone in a multi-site trial. J Neuroimmune Pharmacol. 2018;13(4):488-497. doi:10.1007/s11481-018-9801-x
13.
GuoCZD’OnofrioGFiellinDA, et al. Emergency department-initiated buprenorphine protocols: a national evaluation. J Am Coll Emerg Physicians Open. 2021;2(6):e12606. doi:10.1002/emp2.12606
14.
D’OnofrioGO’ConnorPGPantalonMV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
15.
D’OnofrioGChawarskiMCO’ConnorPG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. J Gen Intern Med. 2017;32(6):660-666. doi:10.1007/s11606-017-3993-2
16.
StrayerRJHawkKHayesBD, et al. Management of opioid use disorder in the emergency department: a white paper prepared for the American academy of emergency medicine. J Emerg Med. 2020;58(3):522-546. doi:10.1016/j.jemermed.2019.12.034
17.
WaxPMStolbachAISchwarzESWarrickBJWiegandTJNelsonLS.ACMT position statement: buprenorphine administration in the emergency department. J Med Toxicol. 2019;15(3):215-216. doi:10.1007/s13181-019-00712-3
18.
FoxLNelsonLS.Emergency department initiation of buprenorphine for opioid use disorder: current status, and future potential. CNS Drugs. 2019;33(12):1147-1154. doi:10.1007/s40263-019-00667-7
19.
KaucherKACarusoEHSungarG, et al. Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program. Am J Emerg Med. 2020;38(2):300-304. doi:10.1016/j.ajem.2019.158373
20.
JonesCMCampopianoMBaldwinGMcCance-KatzE.National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105(8):e55-e63. doi:10.2105/AJPH.2015.302664
21.
Dickson-GomezJKrechelSOhlrichJ, et al. “They make it too hard and too many hoops to jump”: system and organizational barriers to drug treatment during epidemic rates of opioid overdose. Harm Reduct J. 2024;21(1):52. doi:10.1186/s12954-024-00964-5
22.
HawkKFD’OnofrioGChawarskiMC, et al. Barriers and facilitators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. doi:10.1001/jamanetworkopen.2020.4561
23.
RosenbergNKHillABJohnskyLWiegnDMerchantRC.Barriers and facilitators associated with establishment of emergency department-initiated buprenorphine for opioid use disorder in rural Maine. J Rural Health. 2022;38(3):612-619. doi:10.1111/jrh.12617
24.
BozinoffNGrennellESoobiahC, et al. Facilitators of and barriers to buprenorphine initiation in the emergency department: a scoping review. Lancet Reg Health Am. 2024;38. doi:10.1016/j.lana.2024.100899
GlasgowREHardenSMGaglioB, et al. RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review. Front Public Health. 2019;7. Accessed June 1, 2022. https://www.frontiersin.org/article/10.3389/fpubh.2019.00064
27.
TongASainsburyPCraigJ.Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042
28.
VaismoradiMTurunenHBondasT.Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398-405. doi:10.1111/nhs.12048
29.
EdwardsFJWicelinskiRGallagherNMcKinzieAWhiteRDomingosA.Treating opioid withdrawal with buprenorphine in a community hospital emergency department: an outreach program. Ann Emerg Med. 2020;75(1):49-56. doi:10.1016/j.annemergmed.2019.08.420
30.
SkainsRMReynoldsLCarlisleN, et al. Impact of emergency department-initiated buprenorphine on repeat emergency department utilization. West J Emerg Med. 2023;24(6):1010-1017. doi:10.5811/westjem.60511
31.
BoganCJenningsLHaynesL, et al. Implementation of emergency department–initiated buprenorphine for opioid use disorder in a rural southern state. J Subst Abuse Treat. 2020;112:73-78. doi:10.1016/j.jsat.2020.02.007
32.
HutchinsonECatlinMAndrillaCHABaldwinLMRosenblattRA.Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med. 2014;12(2):128-133. doi:10.1370/afm.1595
33.
KellyTDHawkKFSamuelsEAStrayerRJHoppeJA.Improving uptake of emergency department-initiated buprenorphine: barriers and solutions. West J Emerg Med. 2022;23(4):461-467. doi:10.5811/westjem.2022.2.52978
34.
CaoSSDunhamSISimpsonSA.Prescribing buprenorphine for opioid use disorders in the ED: a review of best practices, barriers, and future directions. Open Access Emerg Med. 2020;12(null):261-274. doi:10.2147/OAEM.S267416
35.
LowensteinMKilaruAPerroneJ, et al. Barriers and facilitators for emergency department initiation of buprenorphine: a physician survey. Am J Emerg Med. 2019;37(9):1787-1790. doi:10.1016/j.ajem.2019.02.025
MichelsCSchneiderTTetreaultKPayneJMZubkeKSalisbury-AfsharE.Attitudes, beliefs, barriers, and facilitators of emergency department nurses toward patients with opioid use disorder and naloxone distribution. West J Emerg Med. 2024;25(4):444-448. doi:10.5811/westjem.18020
38.
KawasakiSFrancisEMillsSBuchbergerGHogentoglerRKraschnewskiJ.Multi-model implementation of evidence-based care in the treatment of opioid use disorder in Pennsylvania. J Subst Abuse Treat. 2019;106:58-64. doi:10.1016/j.jsat.2019.08.016
39.
CisewskiDHSantosCKoyfmanALongB.Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. Am J Emerg Med. 2019;37(1):143-150. doi:10.1016/j.ajem.2018.10.013
40.
TreitlerPCrystalSCantorJ, et al. Emergency department peer support program and patient outcomes after opioid overdose. JAMA Netw Open. 2024;7(3):e243614. doi:10.1001/jamanetworkopen.2024.3614
41.
JustenMEdelmanEJChawarskiM, et al. Perspectives on and experiences of emergency department–initiated buprenorphine among clinical pharmacists: a multi-site qualitative study. J Subst Use Addict Treat. 2023;155:209058. doi:10.1016/j.josat.2023.209058
