7 minute read
Carrots, Education, and Hopefully Not Too Many Sticks: A Study in Behavior Change
By Dana L. Sacco, MD, MSc; Betty Chang, MD; and Bernard P. Chang, MD, PhD
Like many emergency departments (EDs) nationwide, we have seen an alarming rise in patients presenting with opioid overdoses, opioid-related complaints, and patients with separate medical complaints but a concurrent opioid X-Waiver Training Coming June 8! use disorder (OUD). The data supporting the use of Join SAEM on June 8 from noon to buprenorphine as a treatment for OUD is mounting, and importantly, so is the data demonstrating that it can be safely initiated from the ED. Yet until recently, buprenorphine 4 p.m. CT for virtual emergency medicine X-waiver training. At the conclusion of the treatment in the ED has remained uncommon despite training, participants will be credentialed rising numbers of ED patients who would potentially be to apply for their DATA 2000 (X) waiver and eligible. Buprenorphine treatment, and more broadly, ED administered mental health interventions, have increasingly been shown to have positive benefit for patients, yet such prepared to manage opioid use disorder patients. Register today! adoptions require behavioral and practice changes on the part of clinicians and departments nationwide. What are strategies for helping to encourage and motivate clinicians to adapt? Past work in cognitive and organizational psychology has found the science of behavior change (e.g., motivating individuals to adopt new activities or attitudes) to be driven in part by intrinsic (e.g., selfmotivation, attitudinal changes) and extrinsic factors (e.g., external rewards, punishments etc.). to reverse this requirement, a change long supported by drug addiction and public health experts, these steps have since been rolled back, leaving clinicians (at the time of this writing) still responsible for obtaining this license. From an administrative standpoint, for our ED, buprenorphine was an acute psychiatric medication historically prescribed by addiction psychiatrists, with the ED pharmacy less familiar and therefore less comfortable with the medication profile in the medical ED setting. These approaches have broad implications for not Provider-level hesitancy may also be at play. When it comes only patient care (e.g., treatment adherence) but also with to patients with OUD, we have historically had few medications regards to behavior change in clinicians. Understanding in our armamentarium. As ED providers, mental health and strategies to influence change and adaptation in clinicians particularly substance use complaints have been among the can facilitate operationalizing department-wide changes in conditions we may be all too happy to refer to a consultant practice management, patient care, and culture. or sub-specialist. Even common opioid-related medications
Like many EDs across the country, we sought to change our approach to patients with OUD yet encountered numerous challenges, from individual provider hesitation to system-level hurdles in the adoption of new practice guidelines. Our primary questions were: How do we increase the number of X-waivered providers in our ED? And for those with X-waivers, how do we encourage clinicians to administer buprenorphine for eligible patients? In this perspectives piece we share our multi-pronged approach to that we encounter in our practice, such as methadone, are not typically prescribed or managed by acute care providers, and many of us have seen firsthand the abuse potential. For some providers buprenorphine may appear to fall into a similar category: a medicine with which providers may have limited experience, treating a population of patients who may have challenges with follow-up and adherence. And what’s more, with more regulatory red tape and additional mandatory training. Why would I prescribe that? cultural change and provider education regarding OUD and Aside from the X-waiver, another potential obstacle to ED buprenorphine. Our hope is that in sharing this experience, providers prescribing buprenorphine is a knowledge gap in others may draw generalizable takeaways with regards to terms of its mechanism and administration. Addressing this motivating faculty across the professional career lifespan on gap could potentially reduce the hesitancy on the part of practice adaptation and change. providers for prescribing an “opiate.” For example, because In addressing these challenges (increasing X-waiver providers and ultimately increasing buprenorphine administration), an exploration of the potential causes underlying our behavior may shed light on the issue. Why do so few ED providers prescribe buprenorphine? Several external factors may be responsible. From a regulatory standpoint, buprenorphine is a partial opioid agonist with a ceiling effect, patients don’t become high when they take it orally. And because the preparation suboxone is a combination of buprenorphine plus naloxone, if an industrious user learns how to inject it, the naloxone will become active and will prevent an opioid high as well. a special license called an “X-waiver” is needed to write a Our aim in disseminating information with regards to prescription for buprenorphine, thus requiring additional buprenorphine induction is not to make ED providers addiction training and regulatory processes to complete. Though there were steps taken by the U.S. Department of Health and Human Services at the end of the last administration continued on Page 52
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psychiatrists. However, we do not need to be infectious disease specialists to prescribe antibiotics, nor endocrinologists or cardiologists to prescribe a patient with new onset diabetes or hypertension a short prescription of antihypertensives or glycemic agents until they are able to see their primary care doctor. And though we may not always initiate these types of medications, many ED providers are comfortable doing so, provided there is coordination of timely outpatient follow up. Buprenorphine should be the same.
Our goal of increasing both X-waivered providers and buprenorphine prescriptions required a three-pronged approach: education (intrinsic motivation, empowerment), collaboration (interdisciplinary coordination with key stakeholders) and administrative (external reward and recognition).
Education
Discussions with our providers on the usage and pharmacokinetics of buprenorphine were carried out at faculty meetings as well as through emails and by a committee we created to address this issue, known as the ED Buprenorphine Task Force. Safe practices for buprenorphine were codified into practice guidelines for our department and posted in clinical areas where providers could easily find and refer to them. Additionally, we created a rotating roster of several X-waivered physicians who were available to help determine patient eligibility, provide education, and ultimately send the prescription if the treating physician had not yet obtained an X-waiver. This physician on-call structure was intended to be a finite resource while our group of providers as a whole obtained their X-waiver licenses and became more familiar with the prescription of buprenorphine. These physicians served as peer supporters who could guide and encourage colleagues to adopt new treatment strategies in the ED setting.
Collaboration
We assembled a multidisciplinary group to facilitate the prescription of buprenorphine from the ED. This group was composed of ED pharmacists, nurse educators, and our colleagues in the psychiatric ED. We worked together with our pharmacy to prepare for the safe and more frequent usage of buprenorphine in the medical ED. Our psychiatric ED colleagues have been prescribing buprenorphine for a longer time, and we involved them in our rollout of buprenorphine guidelines as well.
Administrative
Complementing our education efforts and peer supporters, we also included external incentives to increase the number of providers with X-waivers. Recent work has described the use of financial incentives to encourage X-waivered participation with positive success. First, with departmental support, we began with a time-sensitive external incentive bonus for providers in the early months of the X-waiver program rollout, then subsequently with a broader mandate for all providers to fulfill X-waiver training by the next academic year. Recognizing the additional administrative and regulatory steps for the training, we hoped that providing some external reward/ recognition would help bolster engagement with our educational program and ultimately increase comfort with buprenorphine management in the ED.
From an initial uptake of two providers who were X-waivered prior to our program, we now have over 50 ED faculty with X-waivers. Additionally, prior to the start of our effort we had zero ED-initiated buprenorphine inductions in the ED, and we are now averaging one to two new buprenorphine inductions a week.
The number of X-waivered ED physicians has been reported to be around 7% nationwide (according to data kept by the Substance Abuse and Mental Health Services Administration), and most of these providers are concentrated in urban areas and academic centers. As recently as 2018 up to half of rural counties have been reported to have no X-waivered providers. Strategizing ways to motivate and increase the adoption of such treatment strategies for ED providers should consider leveraging a combination of externally- and internallyguided strategies to encourage new treatment approaches. Ultimately, such multipronged methods may lead to the adoption of dynamic and evidence based clinical practices benefiting the patients we serve.
ABOUT THE AUTHORS
Dr. Sacco is a practicing emergency physician at NewYork-Presbyterian/Columbia University Irving Medical Center and is involved with substance use disorder research.
Dr. Betty Chang is the medical director at NewYorkPresbyterian/Columbia University Irving Medical Center Adult Emergency Department. She is a practicing emergency physician and leads the departmental ED-Buprenorphine Task Force.
Dr. Bernard Chang is a research psychologist and practicing emergency physician. He is currently vice chair of research and associate professor of emergency medicine in the department of emergency medicine at Columbia University.
