What you need to know
Buprenorphine initiation in the emergency department (ED) in people who have an opioid overdose is an evidence-based strategy that saves lives. However, only 3% to 15% of those who are treated for an opioid-related overdose in the ED fill a prescription for buprenorphine at discharge. Researchers conducted a review of publications that described the barriers and facilitators to buprenorphine initiation in the ED. The results show there has not been a coordinated approach to implementing the intervention at the national level in the United States or Canada. This has made it difficult for many EDs and health systems to successfully implement and adapt the intervention. Facilitators buprenorphine initiation in the ED include use of multidisciplinary addiction teams and co-located, low-barrier, harm reduction-informed services to support transitions. Barriers include a failure to address structural stigma, client complexity, and the toxic drug supply.
What is this research about?
Buprenorphine is an evidence-based treatment for people with opioid use disorder (OUD) and saves lives in people who have an opioid overdose. Buprenorphine initiation in the ED is an evidence-based strategy to mitigate the opioid overdose crisis.
Although its use has been increasing, only 3% to 15% of individuals treated for opioid-related overdose in EDs fill a buprenorphine prescription at discharge.
What did the researchers do?
Researchers conducted a systematic review of academic publications to identify the barriers and facilitators to prescribing buprenorphine in the ED. The researchers specifically looked at the use of buprenorphine as opioid agonist therapy, as treatment for opioid use disorder, or as a harm reduction strategy.
What did the researchers find?
They reviewed 361 articles. Most studies were conducted in the United States (89.5%), followed by Canada (9.7%), Australia (0.5%), and France (0.3%). Some examples of the facilitators and barriers identified through this review are listed below. They are categorized according to the health system, state, or country level, the individual ED level, the service provider and client levels, as well as the innovation (buprenorphine) and implementation process levels.
Health System, State, or Country
Facilitators: Relaxation of the requirement that physicians receive specific training and certification to prescribe buprenorphine for OUD; legislation requiring hospitals with EDs to offer opioid agonist therapy and addiction treatment; policies increasing the types of healthcare providers allowed to prescribe buprenorphine.
Barriers: Negative attitudes towards patients with OUD and toward buprenorphine; lack of outpatient follow-up; operational issues (eg, clinic hours of operation, lack of transportation, long wait times).
Individual ED
Facilitators: Use of multidisciplinary teams; longer prescriptions and to-go kits; facilitation of transportation for clients.
Barriers: Difficulties with warm handoff; uneven power dynamics between service providers and clients; discrimination based on client characteristics (eg, race, age); client experiences and anticipation of poor quality care.
Individual Service Provider and Service User
Facilitators: Support from leadership; service provider comfort with prescribing buprenorphine; service provider motivation and positive experiences starting clients on buprenorphine.
Barriers: Service provider discomfort related to when and how to prescribe buprenorphine; service provider difficulty building rapport with client; lack of knowledge about how to access opioid agonist therapy.
Innovation (Buprenorphine)
Facilitators: Evidence supporting buprenorphine use in the ED; service provider perception that buprenorphine is better than current practice; cost savings.
Barriers: Criticisms of initial study methods, lack of consideration of youth-specific issues; high up-front investment.
Implementation Process
Facilitators: Use of an interdisciplinary leadership team; site-specific adaptations; novel or flexible induction strategies (eg, home induction, macrodosing, microdosing).
Barriers: Unsuccessful stakeholder engagement; failure to tailor induction protocols and training to ED setting; failure to adapt to evolving drug supply.
Limitations of the research
The paper’s authors did not review information produced outside of traditional publishing and distribution channels. They noted that including other types of publications and articles in languages other than English and French would have provided a more comprehensive picture. They also noted that the literature provided limited information about participant characteristics or social positions (eg, race, gender, sex, sexuality, housing status and rurality), which may limit the interpretation of the findings.
How can you use this research?
This research can help hospitals optimize the implementation of ED-based buprenorphine and opioid agonist therapy. Consideration of the structures of oppression and power dynamics identified in this study can help implement a more accessible and equitable ED response to the opioid crisis.
About the researchers
Nikki Bozinoff,1,2 Erin Grennell,2,3 Charlene Soobiah,4 Zahraa Farhan,5 Terri Rodak,6 Christine Bucago,7 Katie Kingston,8 Michelle Klaiman,9 Brittany Poynter,7,10 Dominick Shelton,11 Elizabeth Schoenfeld,12 and Csilla Kalocsaij,13
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1001 Queen Street W, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, Canada
- Temerty School of Medicine, University of Toronto, 1 King’s College Circle, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, Ontario, Canada
- Major Program in Mental Health Studies, University of Toronto, 1265 Military Trail, Scarborough, Ontario, Canada
- CAMH Mental Health Sciences Library, Department of Education, Centre for Addiction and Mental Health, 1025 Queen Street W, Toronto, Ontario, Canada
- Gerald Sheff and Shanitha Kachan Emergency Department, Centre for Addiction and Mental Health, 1051 Queen Street W, Toronto, Ontario, Canada
- Youth Advisory Group, Margaret and Wallace McCain Centre for Child, Youth & Family Mental Health and the Child, Youth and Emerging Adult Program, Centre for Addiction and Mental Health, 80 Workman Way, Toronto, Ontario, Canada
- Department of Emergency Medicine, Unity Health Toronto-St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada
- Department of Emergency Medicine, Department of Healthcare Delivery and Population Science UMass Chan- Baystate, 3601 Main St, Springfield, MA, United States
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada