emergency

Pharmacist-Led Program Cuts ED Visits for OUD

Stocking treatments in ADCs, boosting X-waivered physicians among key strategies

By Gina Shaw

An opioid use disorder (OUD) initiative led by emergency department (ED) pharmacists contributed to a decrease in OUD-related ED visits at Boston Medical Center (BMC) over three years, even as such visits were on the rise nationwide, according to a study presented at the ASHP 2021 Midyear Clinical Meeting and Exhibition, held virtually.

The initiative focused on improving access to medications for OUD (MOUD)—as well as the opioid overdose reversal agent naloxone—and developing ED-specific guidelines for OUD treatment, the study showed.

After implementation, monthly ED visits related to OUD declined from more than 200 in September 2017 to between 150 and 175 visits per month by September 2021, according to the researchers.

The results came as ED visits for OUD across the country increased by 10.5% (n=3,486; 95% CI, 4.18%-17.0%) in 2020 compared with 2018 and 2019 (n=3,020 and n=3,285, respectively), according to one study (Ann Emerg Med 2022;79[2]:158-167).

The results show “pharmacists are essential to improving access to and treatment for OUD,” the researchers said.

Overcoming Barriers

Emergency departments are a common touch point for OUD patients to receive MOUD such as buprenorphine, methadone and naltrexone, which are considered standard-of-care treatments, said Natalija Farrell, PharmD, a pharmacy clinical coordinator in emergency medicine at BMC and an assistant professor of emergency medicine at Boston University School of Medicine.

However, “patients encounter multiple barriers to accessing MOUD, including ... stigma, failure to stock buprenorphine at pharmacies and insufficient numbers of DEA [Drug Enforcement Administration] X-waivered providers and opioid treatment programs,” Dr. Farrell said.

She noted that up to 9% of patients die within a year after a nonfatal overdose—20% of which occurred within one month.

At BMC, a multidisciplinary work group consisting of ED physicians, nurses and pharmacists, addiction medicine physicians, and licensed drug and alcohol counselors developed strategies to improve the treatment of patients with OUD in the ED.

Those strategies, which were implemented beginning in September 2018, included: • stocking MOUD in the ED’s automated dispensing cabinets; • providing incentives for ED physicians to obtain DEA X-waivers, which increased the percentage of DEA X-waivered ED providers from approximately 5% to approximately 90%; • daily education from ED pharmacists at morning and evening nursing huddles; • education at the emergency medicine physicians’ educational conferences during Recovery Month each

September; and • collaborating with BMC’s substance use disorders bridge clinic, Faster

Paths, to allow walk-in availability for patients just discharged from the ED.

“This paper really highlights the importance of a multidisciplinary approach to an effort like this,” said Kyle Weant, PharmD, BCPS, a clinical assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy, in Columbia, who was not involved in the study. “Pharmacists are helpful not only in terms of the logistics, but the patient education and connecting different entities and disciplines together. Then, of course, you have to have physician prescribers, nurses, social workers and others on board, because they are also integral to this process of identifying patients in need of intervention and echoing the messaging that we’re trying to deliver to those patients.”

Take-Home Naloxone Program

The initiative also focused on ensuring people being treated for OUD had access to the opioid overdose medication naloxone.

However, funding became an issue when a state grant for naloxone distribution was not renewed in July 2018. To keep the program going, the working group coordinated with the state board of pharmacy and the outpatient pharmacy to develop a retrospective reimbursement process, which went live in September 2018. Once a week, the ED pharmacy manager brought all naloxone prescriptions to the outpatient pharmacy liaison to submit for reimbursement. According to the study, 88% of the prescriptions were covered by insurance, and the remainder were provided at no cost to the patient due to lack of insurance or insurance copay requirements.

By January 2020, ED pharmacists began providing discharged patients with buprenorphine-naloxone take-home kits that included one naloxone 4-mg spray and four buprenorphine-naloxone 8-mg/2-mg films, as well as medication handouts and brochures for the Faster Paths bridge clinic, Dr. Farrell said.

She said 76.7% of patients who received the buprenorphine-naloxone take-home kits presented at the bridge clinic within seven days of discharge, compared with 42.7% who received only a buprenorphine-naloxone prescription (P<0.001).

“This, to me, is the biggest takeaway from this project—that providing the patients with the kits was very effective in increasing the likelihood that they would be connected to the bridge clinic,” Dr. Weant said. “In hindsight, of course, that seems like an obvious concept, but it’s something that we unfortunately need to continue to prove to the world, that this is worth doing and worth paying for.”

Doing Better With Funding

Although Dr. Weant’s current ED does not provide the take-home kits, his previous practice at the Medical University of South Carolina offered kits with naloxone and were working toward adding buprenorphine.

“We were fortunate to have a grant from the state to facilitate that,” he said. “That’s one thing that can be frustrating. As was the experience for the authors of this paper, you can do great programs with funding from the state or some other entity, but then the grant funding runs out. We need to do better as a society about having sustained and recurrent funding for programs like these.”

‘This paper really highlights the importance of a multidisciplinary approach to an effort like this.’

—Kyle Weant, PharmD

Natalija Farrell, PharmD, and her emergency department pharmacist colleagues at Boston Medical Center have improved treatment access for patients with OUD.

The sources reported no relevant fi nancial disclosures.