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Shifting Tides: Changing the Paradigm of Treating Opioid Use Disorder by Updating Resident Education
By Corey Hazekamp, MD, MS; Dana Sacco, MD, MS; and Bernard Chang MD, PhD
This article highlights work from the 2022 NIDA Mentor-Facilitated Training Award, supported by the National Institute on Drug Abuse (NIDA) from the National Institutes of Health (NIH) and sponsored by the SAEM Foundation Emergency medicine has long been the front line of patient care for a diverse range of acute and chronic conditions and the clinical milieu where providers can support some of the most vulnerable patients in health care. In the face of the recent opioid epidemic striking our health care system, Emergency departments (ED) have faced increasing numbers of patient with behavioral health concerns and substance use disorder complications. At the onset of my career as an emergency medicine provider, treating patients with opioid use disorder (OUD) in the ED was a humbling experience that inspired me to learn more. However, I quickly encountered the challenges of utilizing life-saving medications for opioid use disorder (MOUD) in the ED, specifically how to initiate buprenorphine. I soon learned of the NIDA MentorFacilitated Training Award, supported by the National Institute on Drug Abuse (NIDA) from the National Institutes of Health (NIH) and sponsored by SAEM Foundation. My plan was to learn how to overcome barriers to EDinitiated buprenorphine as a resident and disseminate information to other residents interested in learning how to counteract the ongoing opioid epidemic. The result of the project that I proposed, “Shifting Tides: Changing the Paradigm of Treating Opioid Use Disorder by Updating Resident Education,” is a framework we conceptualize as “The 3B’s of Buprenorphine: Basics, Barriers and Beyond the ED.” This framework was created with the intent of helping to better educate residents, as well as other ED providers, about how to successfully initiate buprenorphine treatment in the ED.
In our framework, the Basic reason to offer buprenorphine to patients with OUD in the ED is that it decreases mortality. A randomized control trial showed that patients who are initiated on buprenorphine in the ED had increased retention in treatment and decreased self-reported opioid use. When a patient comes to the ED in opioid withdrawal, if untreated, they are more likely to return to opioid use upon discharge, increasing their risk of overdose and possibly death. Furthermore, there are clinical benefits to using buprenorphine in the ED. Compared to methadone, buprenorphine has less of a risk of apnea and QTc prolongation.
The Barriers addressed in our framework include (1) learning how and when to initiate buprenorphine in the
ED, (2) working in a department without a protocol for ED-initiated buprenorphine, and (3) addressing internal biases that may prevent us from offering MOUD. There is no unified protocol or algorithm for how and when to initiate buprenorphine. The American Journal of Emergency Medicine and Annals of Emergency Medicine have both published guidelines for ED-initiated buprenorphine. Resources that ED providers can utilize in real time when encountering opioid withdrawal include MDCalc’s Emergency Department-Initiated Buprenorphine for Opioid Use Disorder (EMBED) tool and the BUP Initiation app, both of which include a screening tool to evaluate for OUD, a brief negotiating interview, the clinical opioid withdrawal score (COWS), dosing, and discharge instructions. The X-waiver has long been considered a barrier to emergency physicians (EPs) prescribing buprenorphine. The Drug Addiction Treatment Act of 2000 requires eligible providers to complete eight hours of training to obtain what is known as an “X-waiver” in order to prescribe buprenorphine. Adjustments made during the COVID-19 pandemic led to the creation of a notification of intent (NOI) which allows providers to discharge patients with buprenorphine prescriptions without any additional training. If a provider does not have an X-waiver, they can still order buprenorphine while a patient is in the ED and have the patient return to the ED later for additional dosing if necessary. An option for a patient whose withdrawal is not yet severe enough for buprenorphine in the ED is to provide instructions for home induction of buprenorphine. Patients can be discharged with a prescription for buprenorphine and specific instruction on induction. The Buprenorphine Home Induction app provides step-by-step instruction on how to do a buprenorphine home induction and also provides a search function to find a buprenorphine provider.
Another potential barrier and/or challenge to patients being offered buprenorphine in the ED occurs at the operational and clinician level. Humans experience cognitive biases daily – a deviation in our thought processes based on external influences. We’re also vulnerable to utilizing heuristics, a type of cognitive shortcut, to make decisions quickly. Previous research has shown that cognitive biases may lead to diagnostic inaccuracies or premature diagnostic closure. In a recent paper, Dr. Dan Ly found that EPs were vulnerable to the availability heuristic – that our assessment of an event’s likelihood of occurring is influenced by how easily this event comes to mind. In other words, we’re more likely to think of a diagnosis if we have seen it recently. This may have implications when managing patients with OUD in the ED. A recent unpleasant experience with a patient who has OUD may or may not have led us to believe that this patient was exhibiting drug-seeking behavior. Regardless, we should all make a conscious effort to prevent this kind of previous experience from influencing our approach to the patient in front of us. All patients deserve to be offered comprehensive care and treatment, which includes MOUD such as buprenorphine for patients with OUD.
Finally, the Beyond the ED portion of our framework encompasses one of the most important components of initiating buprenorphine in the ED: linkage to long-term treatment. Not all hospitals are created equally; we work in a wide variety of environments and have access to different resources. Patients who undergo ED-initiated buprenorphine require long-term follow up. Three common models used by ED providers are (1) the Bridge model, (2) the ED-Bridge model, and (3) the Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model. The Bridge model requires an ED provider to initiate buprenorphine in the ED and the patient follows up with a different provider in the same hospital; whereas in the ED-Bridge model the ED provider initiates buprenorphine in the ED and can serve as a longterm buprenorphine provider. ASSERT utilizes addiction team services along with peer educators and community workers. Some states have extensive referral systems such as California, CA Bridge, and New York, NY MATTERS. If none of these are available within your hospital, harm-reduction clinics are useful resources, and some offer buprenorphine treatment. Familiarizing yourself with the resources your department, hospital, and community have for patients with OUD will take a small amount of time but will be invaluable in helping serve some of the most in-need patients that visit the ED.
Unlike ACLS guidelines which dictate when and how much epinephrine and amiodarone to give while resuscitating a patient in cardiac arrest, there is not a single set of guidelines regarding the timing and dosing of buprenorphine. Most current emergency medicine residents likely do not train in a department with a protocol for initiating buprenorphine. And there is no specific ACGME requirement for teaching residents how to initiate buprenorphine. Despite these limitations, we hope to help residents recognize the importance of offering MOUD, especially buprenorphine, to their patients with OUD. Clinicians practicing emergency medicine are passionate advocates for their patients. We sustain this passion and carry it over to how we treat all our patients. For some of society’s most vulnerable patients, such as those with substance use disorders, EPs can play a vital role in supporting their short and longterm wellbeing. Hopefully the resources provided here can help anyone interested get started in learning how to appropriately initiate buprenorphine in the ED.
ABOUT THE AUTHORS
Dr. Hazekamp is a secondyear emergency medicine resident at NYC H+H/Lincoln. He is interested in researching healthcare disparities. @coreyhazekamp
Dr. Chang is vice chair of research and associate professor of emergency medicine at Columbia University, with research interests in health psychology, clinician health, and neuropsychiatric disease Dr. Sacco is a practicing emergency physician at NYP-Columbia University Irving Medical Center, and is involved with substance use disorder research
Dr. Hazekamp talks about his research…
