Special Issue on Substance Misuse and Addiction Disorders by Western Journal of Emergency Medicine

Penn State Health Emergency Medicine

About Us:

Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are the only medical facility in Pennsylvania to be accredited as a Level I pediatric trauma center and Level I adult trauma center. The system includes Penn State Health Milton S. Hershey Medical Center, Penn State Health Children’s Hospital, and Penn State Cancer Institute based in Hershey, Pa.; Penn State Health Hampden Medical Center in Enola, Pa.; Penn State Health Holy Spirit Medical Center in Camp Hill, Pa.; Penn State Health St. Joseph Medical Center in Reading, Pa.; Penn State Health Lancaster Pediatric Center in Lancaster, Pa.; Penn State Health Lancaster Medical Center (opening fall 2022); and more than 3,000 physicians and direct care providers at more than 126 outpatient practices in 94 locations. Additionally, the system jointly operates various health care providers, including Penn State Health Rehabilitation Hospital, Hershey Outpatient Surgery Center, Hershey Endoscopy Center, Horizon Home Healthcare and the Pennsylvania Psychiatric Institute.

We foster a collaborative environment rich with diversity, share a passion for patient care, and have a space for those who share our spark of innovative research interests. Our health system is expanding and we have opportunities in both academic hospital as well community hospital settings.

Benefit highlights include:

• Competitive salary with sign-on bonus

• Comprehensive benefits and retirement package

• Relocation assistance & CME allowance

• Attractive neighborhoods in scenic central Pa.

Western Journal of Emergency Medicine: Integrating

Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Co-Guest Editors

Gentry Wilkerson, MD, Associate Editor University of Maryland

Alexis M. LaPietra MD, Associate Editor RWJ Barnabus Health-West Orange, New Jersey

Resident Editors

AAEM/RSA

John J. Campo, MD

Harbor-University of California, Los Angeles Medical Center

Tehreem Rehman, MD

Advocate Christ Medical Center

ACOEP

Justina Truong, DO Kingman Regional Medical Center

Section Editors

Behavioral Emergencies

Erin Dehon, PhD University of Mississippi Medical Center

Leslie Zun, MD, MBA Chicago Medical School

Marc L. Martel, MD

Hennepin County Medical Center

Cardiac Care

Fred A. Severyn, MD

University of Colorado School of Medicine

Michael C. Kurz, MD University of Alabama at Birmingham

Sam S. Torbati, MD

Cedars-Sinai Medical Center

Yanina Purim-Shem-Tov, MD, MS Rush University Medical Center

Clinical Practice

Cortlyn W. Brown, MD Carolinas Medical Center

Casey Clements, MD, PhD Mayo Clinic

Patrick Meloy, MD Emory University

Nicholas Pettit, DO, PhD Indiana University

Eric Snoey, MD Alameda County Medical Center

David Thompson, MD University of California, San Francisco

Kenneth S. Whitlow, DO Kaweah Delta Medical Center

Critical Care

Christopher “Kit” Tainter, MD University of California, San Diego

Gabriel Wardi, MD University of California, San Diego

Joseph Shiber, MD University of Florida-College of Medicine

Matt Prekker MD, MPH Hennepin County Medical Center

Edward Michelson, MD, Associate Editor Texas Tech University- El Paso, Texas

Mark I. Langdorf, MD, MHPE

University of California, Irvine School of MedicineIrvine, California

Michael Gottlieb, MD, Associate Editor Rush Medical Center-Chicago, Illinois

Niels K. Rathlev, MD, Associate Editor Tufts University School of Medicine-Boston, Massachusetts

Rick A. McPheeters, DO, Associate Editor Kern Medical- Bakersfield, California

Patrick Joseph Maher, MD, MS, Associate Editor Ichan School of Medicine at Mount Sinai, New York

David Page, MD University of Alabama

Erik Melnychuk, MD

Geisinger Health

Quincy Tran, MD, PhD University of Maryland

Disaster Medicine

Christopher Kang, MD

Madigan Army Medical Center

Gentry Wilkerson, MD University of Maryland

Education

Danya Khoujah, MBBS University of Maryland School of Medicine

Jeffrey Druck, MD University of Colorado

John Burkhardt, MD, MA University of Michigan Medical School

Michael Epter, DO Maricopa Medical Center

ED Administration, Quality, Safety

David C. Lee, MD

Northshore University Hospital

Gary Johnson, MD

Upstate Medical University

Brian J. Yun, MD, MBA, MPH

Harvard Medical School

Laura Walker, MD

Mayo Clinic

León D. Sánchez, MD, MPH

Beth Israel Deaconess Medical Center

William Fernandez, MD, MPH University of Texas Health-San Antonio

Emergency Medical Services

Daniel Joseph, MD

Yale University

Joshua B. Gaither, MD

University of Arizona, Tuscon

Julian Mapp

University of Texas, San Antonio

Shira A. Schlesinger, MD, MPH

Harbor-UCLA Medical Center

Geriatrics

Cameron Gettel, MD

Yale School of Medicine

Stephen Meldon, MD

Cleveland Clinic

Luna Ragsdale, MD, MPH

Duke University

Health Equity

Emily C. Manchanda, MD, MPH

Boston University School of Medicine

Shadi Lahham, MD, MS, Deputy Editor University of California, Irvine School of Medicine- Irvine, California

Shahram Lotfipour, MD, MPH, Managing Editor University of California, Irvine School of Medicine- Irvine, California

Susan R. Wilcox, MD, Associate Editor Massachusetts General Hospital- Boston, Massachusetts

Elizabeth Burner, MD, MPH, Associate Editor University of Southern California

Dan Mayer, MD, Associate Editor American College of Emergency Physicians

Andrew W. Phillips, MD, Associate Editor University of North Carolina-Chapel Hill, North Carolina

Mandy J. Hill, DrPH, MPH

UT Health McGovern Medical School

K. Tom Xu, MD, PhD

Texas Tech University Health Sciences Center

Infectious Disease

Elissa Schechter-Perkins, MD, MPH

Boston University School of Medicine

Ioannis Koutroulis, MD, MBA, PhD

Drexel University College of Medicine

Kevin Lunney, MD, MHS, PhD

University of Maryland School of Medicine

Robert Derlet, MD

Founding Editor, California Journal of Emergency Medicine

University of California, Davis

Stephen Liang, MD, MPHS

Washington University School of Medicine

Injury Prevention

Mark Faul, PhD, MA

Centers for Disease Control and Prevention

Wirachin Hoonpongsimanont, MD, MSBATS

Eisenhower Medical Center

International Medicine

Heather A.. Brown, MD, MPH

Prisma Health Richland

Taylor Burkholder, MD, MPH

Keck School of Medicine of USC

Christopher Greene, MD, MPH University of Alabama

Chris Mills, MD, MPH

Santa Clara Valley Medical Center

Shada Rouhani, MD

Brigham and Women’s Hospital

Legal Medicine

Melanie S. Heniff, MD, JD

Indiana University School of Medicine

Greg P. Moore, MD, JD Madigan Army Medical Center

Statistics and Methodology

Shu B. Chan MD, MS

Resurrection Medical Center

Stormy M. Morales Monks, PhD, MPH

Texas Tech Health Science University

Soheil Saadat, MD, MPH, PhD University of California, Irvine

James A. Meltzer, MD, MS

Albert Einstein College of Medicine

Musculoskeletal

Juan F. Acosta DO, MS

Pacific Northwest University

Neurosciences

Antonio Siniscalchi, MD Annunziata Hospital

Rick Lucarelli, MD Medical City Dallas Hospital

William D. Whetstone, MD University of California, San Francisco

Pediatric Emergency Medicine

Paul Walsh, MD, MSc University of California, Davis

Muhammad Waseem, MD Lincoln Medical & Mental Health Center

Deena Berkowitz, MD, MPH

Children’s National Hospital

Donna Mendez, MD, EdD University of Texas-Houston/McGovern Medical School

Cristina M. Zeretzke-Bien, MD University of Florida

Public Health

Jeremy Hess, MD, MPH University of Washington Medical Center

Jacob Manteuffel, MD

Henry Ford Hospital

John Ashurst, DO

Lehigh Valley Health Network

Tony Zitek, MD

Kendall Regional Medical Center

Trevor Mills, MD, MPH

Northern California VA Health Care

Erik S. Anderson, MD

Alameda Health System-Highland Hospital

Technology in Emergency Medicine

Nikhil Goyal, MD

Henry Ford Hospital

Phillips Perera, MD Stanford University Medical Center

Trauma

Pierre Borczuk, MD

Massachusetts General Hospital/Havard Medical School

Toxicology

Brandon Wills, DO, MS Virginia Commonwealth University

Jeffrey R. Suchard, MD University of California, Irvine

Ultrasound

J. Matthew Fields, MD

Thomas Jefferson University

Shane Summers, MD

Brooke Army Medical Center

Robert R. Ehrman

Wayne State University

Ryan C. Gibbons, MD Temple Health

Official Journal of the California Chapter of the American College of Emergency Physicians, the America College of Osteopathic Emergency Physicians, and the California Chapter of the American Academy of Emergency Medicine

Available in MEDLINE, PubMed, PubMed Central, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA.

Editorial and Publishing Office: WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 333 City Blvd, West, Rt 128-01, Orange, CA 92868, USA Office: 1-714-456-6389; Email: Editor@westjem.org

. 1.1: January 2025

Western Journal of Emergency :

Western Journal of Emergency Medicine:

Integrating Emergency with Population Health

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

Editorial Board

Board

Editorial Board

MAAEM

Amin A. Kazzi, MD, MAAEM

Gayle Galleta, MD

Beirut,

The American University of Beirut, Lebanon

The American University of Beirut, Beirut, Lebanon

Brent King, MD, MMM University Texas, Houston

Brent King, MD, MMM University of Texas, Houston

Christopher E. San Miguel, MD

Ohio State University Wexner Medical Center

Christopher E. San Miguel, MD Ohio State University Wexner Medical Center

Christopher E. San Miguel, Ohio State University Wexner Medical Center

Daniel J. Dire, MD

Daniel J. Dire, MD University of Texas Health Sciences Center San Antonio

Daniel J. Dire, MD University Texas Health Sciences Center San Antonio

Douglas Ander, MD Emory University

Douglas Ander, Emory University

Emory University

Edward Michelson, MD Texas Tech University

Edward Michelson, Texas Tech University

Edward Panacek, MD, MPH South

Edward Panacek, MD, MPH University of South Alabama

Edward MD, MPH University South Alabama

Francesco

“Maggiore della Carità,” Novara, Italy

Francesco Della Corte, MD Azienda Ospedaliera Universitaria “Maggiore della Carità,” Novara, Italy

Francesco Della Corte, MD Azienda Ospedaliera Universitaria “Maggiore della Novara, Italy

Elena Lopez-Gusman, JD

California ACEP

Elena Lopez-Gusman, JD California ACEP American College of Emergency

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog,

Sørlandet Sykehus HF, Akershus Universitetssykehus, Lorenskog, Norway

Hjalti Björnsson, MD

Niels K. Rathlev, MD Tufts University School of Medicine

Tufts University School of Medicine

Niels K. Rathlev, MD Tufts University School of Medicine

Scott Zeller, MD

Scott Zeller, MD University of California, Riverside

Hjalti Björnsson, MD Icelandic Society of Emergency Medicine

Hjalti MD Icelandic Society of Emergency Medicine

Jaqueline Le, MD Desert Regional Medical Center

Jaqueline Le, MD Desert Medical Center

Regional

Jeffrey Love, MD

Jeffrey Love, MD The George Washington University School of Medicine and Health Sciences

Jeffrey Love, The George Washington University School of Medicine and Health Sciences

Katsuhiro Kanemaru, MD University of Miyazaki Hospital, Miyazaki, Japan

Katsuhiro Kanemaru, MD University of Hospital, Miyazaki, Japan

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de Chile, Región Metropolitana, Chile

Pablo Aguilera Fuenzalida, MD Pontificia Universidad Catolica de

Peter A. Bell, DO, MBA Baptist Health Sciences University

Bell,

Peter A. Bell, DO, MBA Baptist Health Sciences University

Peter Sokolove, MD University of California, San Francisco

Steven H. Lim, MD Changi General Hospital, Simei, Singapore

Singapore

Steven H. Lim, MD Changi General Hospital, Simei, Singapore

Terry Mulligan, DO, MPH, FIFEM ACEP Ambassador to the Netherlands Society of Emergency Physicians

Terry Mulligan, DO, MPH, FIFEM ACEP Ambassador to the Netherlands

Peter Sokolove, MD University of California, San Francisco

University of California, San Francisco

Wirachin Hoonpongsimanont, MD, MSBATS

Kenneth V. Iserson, MD, MBA University of Arizona, Tucson

The George Washington University School of Medicine and Health Sciences Arizona,

Kenneth V. Iserson, MD, MBA University of Arizona, Tucson

Leslie Zun, MD, MBA Chicago Medical School

Rachel A. Lindor, MD, JD Mayo Clinic

Rachel A. Lindor, MD, JD

Siriraj Hospital, Mahidol University, Bangkok, Thailand

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert Suter, DO, MHA

Robert Suter, DO, MHA UT Southwestern Medical Center

Robert W. Derlet, MD University of California, Davis

University of California, Davis

Robert W. Derlet, MD University of California, Davis

Rosidah Ibrahim, MD Hospital Serdang, Selangor, Malaysia

Linda S. Murphy, MLIS University of California, Irvine School of Medicine

Chicago Medical School Librarian

Linda S. Murphy, MLIS University of California, Irvine School of Medicine Librarian

Advisory Board

Langdorf, MAAEM, FACEP

Mark I. Langdorf, MD, MHPE, MAAEM, FACEP

Scott Rudkin, MD, MBA University of California, Irvine

Scott Rudkin, MD, MBA

Scott Rudkin, MD, MBA University of California, Irvine

Editorial Staff

Staff

American College of Emergency Physicians

Jennifer Kanapicki Comer, MD FAAEM

California Chapter Division of AAEM Stanford University School of Medicine

Kimberly Ang, MBA

DeAnna McNett, CAE

American College of Osteopathic Emergency Physicians

UC Irvine Health School of Medicine

American College of Osteopathic Emergency Physicians

Randall J. Young, MD, MMM, FACEP California ACEP

Kimberly Ang, MBA

American College of Emergency Physicians Kaiser Permanente

UC Irvine Health School of Medicine

Randall J. Young, MD, MMM, FACEP California ACEP

American College of Emergency Physicians

J. American College of Emergency Physicians

Kaiser Permanente

UC Irvine Health School of Medicine

Mark I. Langdorf, MD, MHPE, MAAEM, FACEP UC Irvine Health School Medicine

UC Irvine Health School of Medicine

Robert Suter, DO, MHA

Robert Suter, DO, MHA American College of Osteopathic

American College of Osteopathic Emergency Physicians UT Southwestern Medical Center

Robert Suter, DO, MHA American College of Osteopathic Emergency Physicians UT Southwestern Medical Center

Shahram Lotfipour, MD, MPH FAAEM, FACEP UC Irvine Health School of Medicine

Shahram Lotfipour, MD, MPH FAAEM, FACEP UC Irvine Health School Medicine

Jorge Fernandez, MD, FACEP

Isabelle Nepomuceno, BS Executive Editorial Director

Isabelle Kawaguchi, BS Executive Editorial Director

Ian Olliffe, BS Associate Editorial Director, WestJEM

June Casey, BA Copy Editor

Visha Bajaria, BS WestJEM Editorial Director

Emily Kane, MA WestJEM Editorial Director

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Cassandra Saucedo, MS Executive Publishing Director

Visha Bajaria, BS WestJEM Editorial Director WestJEM

Stephanie Burmeister, MLIS WestJEM Staff Liaison

Cassandra Saucedo, MS WestJEM Publishing Director

Tran Nguyen, BS Associate Editorial Director, CPC-EM

Nicole Valenzi, BA WestJEM Publishing Director

Sheya Aquino, BS Associate Editorial Director

June Casey, BA Copy Editor

Nancy Taki, BS Associate Editorial Director

Jorge Fernandez, MD, UC San Diego Health School of Medicine

UC San Diego Health School of Medicine

Cassandra Saucedo, MS Executive Publishing Director

Nicole Valenzi, BA WestJEM Publishing Director

Alyson Tsai, BS Associate Publishing Director

in Melvyl,

Available in MEDLINE, PubMed, PubMed Central, Europe PubMed Central, PubMed Central Canada, CINAHL, SCOPUS, Google Scholar, eScholarship, Melvyl, DOAJ, EBSCO, EMBASE, Medscape, HINARI, and MDLinx Emergency Med. Members of OASPA. Editorial and Publishing Office: WestJEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA Office: 1-714-456-6389; Email: Editor@westjem.org

Editorial and Publishing Office: JEM/Depatment of Emergency Medicine, UC Irvine Health, 3800 W. Chapman Ave. Suite 3200, Orange, CA 92868, USA

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

JOURNAL FOCUS

Emergency medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.

1 Substance Use and Addiction Disorders : A Call for Increased Screening and Treatment in the Emergency Department

RG Wilkerson, AM LaPietra

3 Implementation and Evaluation of a Bystander Naloxone Training Course

SG Weiner, SA Goldberg, C Lang, M Jarman, CJ Miller, S Li, EW Stanek, E Goralnick

8 Harm Reduction in the Field: First Responders’ Perceptions of Opioid Overdose Interventions

CE Fockele, T Frohe, O McBride, DL Perlmutter, B Goh, G Williams, C Wettemann, N Holland, B Finegood, T Oliphant-Wells, EC Williams, J van Draanen

18 Pragmatic Emergency Department Intervention Reducing Default Quantity of Opioid Tablets Prescribed

DG Johnson, AY Lu, GA Kim, K Trepka, SC Yang, JCC Montoy, MA Juarez

26 Bystanders Saving Lives with Naloxone: A Scoping Review on Methods to Estimate Overdose Reversals

AT Kinoshita, S Saadat, B Chakravarthy

33 Attitudes, Beliefs, Barriers, and Facilitators of Emergency Department Nurses Toward Patients with Opioid Use Disorder and Naloxone Distribution

C Michels, T Schneider, K Tetreault, JM Payne, K Zubke, E Salisbury-Afshar

38 Improving Healthcare Professionals’ Access to Addiction Medicine Education Through VHA Addiction Scholars Program

Z Basarai, M Celedon, N Dieujuste, J Himstreet, J Hoffman, C Pfaff, J Hsiao, R Malstrom, J Smith, M Radeos, T Jorgenson, M Christopher, C Sasson

43 Initiation of Buprenorphine in the Emergency Department: A Survey of Emergency Clinicians

MM Mroczkowski, JT Walkup, PS Walkup

50 A Novel Use of the “3-Day Rule”: Post-discharge Methadone Dosing in the Emergency Department

JK Nikolaides, TH Tran, E Ramsey, S Salib, H Swoboda

56 Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics

G Comstock, N Truszczynski, SS Michael, J Hoppe

63 Impact of Emergency Department-Initiated Buprenorphine on Repeat Emergency Department Utilization

RM Skains, L Reynolds, N Carlisle, S Heath, W Covington, K Hornbuckle, L Walter

Policies for peer review, author instructions, conflicts of interest and human and animal subjects protections can be found online at www.westjem.com.

No. 1.1: January 2025

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

71 Accessibility of Naloxone in Pharmacies Registered Under the Illinois Standing Order P Quincy Moore, K Ellis, P Simmer, M Waetjen, E Almirol, E Salisbury-Afshar, MT Pho

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

This open access publication would not be possible without the generous and continual financial support of our society sponsors, department and chapter subscribers.

Professional Society Sponsors

American College of Osteopathic Emergency Physicians

California American College of Emergency Physicians

Academic Department of Emergency Medicine Subscriber Albany Medical College Albany, NY

Allegheny Health Network Pittsburgh, PA

American University of Beirut Beirut, Lebanon

AMITA Health Resurrection Medical Center Chicago, IL

Arrowhead Regional Medical Center Colton, CA

Baylor College of Medicine Houston, TX

Baystate Medical Center Springfield, MA

Bellevue Hospital Center New York, NY

Beth Israel Deaconess Medical Center Boston, MA

Boston Medical Center Boston, MA

Brigham and Women’s Hospital Boston, MA

Brown University Providence, RI

Carl R. Darnall Army Medical Center Fort Hood, TX

Cleveland Clinic Cleveland, OH

Columbia University Vagelos New York, NY

State Chapter Subscriber

Arizona Chapter Division of the American Academy of Emergency Medicine

California Chapter Division of the American Academy of Emergency Medicine

Florida Chapter Division of the American Academy of Emergency Medicine

International Society Partners

Conemaugh Memorial Medical Center Johnstown, PA

Crozer-Chester Medical Center Upland, PA

Desert Regional Medical Center Palm Springs, CA

Detroit Medical Center/ Wayne State University Detroit, MI

Eastern Virginia Medical School Norfolk, VA

Einstein Healthcare Network Philadelphia, PA

Eisenhower Medical Center Rancho Mirage, CA

Emory University Atlanta, GA

Franciscan Health Carmel, IN

Geisinger Medical Center Danville, PA

Grand State Medical Center Allendale, MI

Healthpartners Institute/ Regions Hospital Minneapolis, MN

Hennepin County Medical Center Minneapolis, MN

Henry Ford Medical Center Detroit, MI

Henry Ford Wyandotte Hospital Wyandotte, MI

Emergency Medicine Association of Turkey Lebanese Academy of Emergency Medicine Mediterranean Academy of Emergency Medicine

California Chapter Division of American Academy of Emergency Medicine

INTEGRIS Health Oklahoma City, OK

Kaiser Permenante Medical Center San Diego, CA

Kaweah Delta Health Care District Visalia, CA

Kennedy University Hospitals Turnersville, NJ

Kent Hospital Warwick, RI

Kern Medical Bakersfield, CA

Lakeland HealthCare St. Joseph, MI

Lehigh Valley Hospital and Health Network Allentown, PA

Loma Linda University Medical Center Loma Linda, CA

Louisiana State University Health Sciences Center New Orleans, LA

Louisiana State University Shreveport Shereveport, LA

Madigan Army Medical Center Tacoma, WA

Maimonides Medical Center Brooklyn, NY

Maine Medical Center Portland, ME

Massachusetts General Hospital/Brigham and Women’s Hospital/ Harvard Medical Boston, MA

Great Lakes Chapter Division of the American Academy of Emergency Medicine

Tennessee Chapter Division of the American Academy of Emergency Medicine

Norwegian Society for Emergency Medicine Sociedad Argentina de Emergencias

Mayo Clinic Jacksonville, FL

Mayo Clinic College of Medicine Rochester, MN

Mercy Health - Hackley Campus Muskegon, MI

Merit Health Wesley Hattiesburg, MS

Midwestern University Glendale, AZ

Mount Sinai School of Medicine New York, NY

New York University Langone Health New York, NY

North Shore University Hospital Manhasset, NY

Northwestern Medical Group Chicago, IL

NYC Health and Hospitals/ Jacobi New York, NY

Ohio State University Medical Center Columbus, OH

Ohio Valley Medical Center Wheeling, WV

Oregon Health and Science University Portland, OR

Penn State Milton S. Hershey Medical Center Hershey, PA

Uniformed Services Chapter Division of the American Academy of Emergency Medicine

Virginia Chapter Division of the American Academy of Emergency Medicine

for Emergency Medicine

To become a WestJEM departmental sponsor, waive article processing fee, receive electronic copies for all faculty and residents, and free CME and faculty/fellow position advertisement space, please go to http://westjem.com/subscribe or contact:

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Email: sales@westjem.org

Sociedad Chileno Medicina Urgencia Thai Association

Western Journal of Emergency Medicine:

Integrating Emergency Care with Population Health

Indexed in MEDLINE, PubMed, and Clarivate Web of Science, Science Citation Index Expanded

This open access publication would not be possible without the generous and continual financial support of our society sponsors, department and chapter subscribers.

Professional Society Sponsors

American College of Osteopathic Emergency Physicians

California American College of Emergency Physicians

Academic Department of Emergency Medicine Subscriber Prisma Health/ University of South Carolina SOM Greenville Greenville, SC

Regions Hospital Emergency Medicine Residency Program St. Paul, MN

Rhode Island Hospital Providence, RI

Robert Wood Johnson University Hospital New Brunswick, NJ

Rush University Medical Center Chicago, IL

St. Luke’s University Health Network Bethlehem, PA

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UMass Chan Medical School Worcester, MA

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Arizona Chapter Division of the American Academy of Emergency Medicine

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Florida Chapter Division of the American Academy of Emergency Medicine

International Society Partners

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University of California, Davis Medical Center Sacramento, CA

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UCSF Fresno Center Fresno, CA

University of Chicago Chicago, IL

University of Cincinnati Medical Center/ College of Medicine Cincinnati, OH

University of Colorado Denver Denver, CO

University of Florida Gainesville, FL

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Emergency Medicine Association of Turkey Lebanese Academy of Emergency Medicine Mediterranean Academy of Emergency Medicine

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Great Lakes Chapter Division of the American Academy of Emergency Medicine

Tennessee Chapter Division of the American Academy of Emergency Medicine

Norwegian Society for Emergency Medicine Sociedad Argentina de Emergencias

University of WashingtonHarborview Medical Center Seattle, WA

University of Wisconsin Hospitals and Clinics Madison, WI

UT Southwestern Dallas, TX

Valleywise Health Medical Center Phoenix, AZ

Virginia Commonwealth University Medical Center Richmond, VA

Wake Forest University Winston-Salem, NC

Wake Technical Community College Raleigh, NC

Wayne State Detroit, MI

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Uniformed Services Chapter Division of the American Academy of Emergency Medicine

Virginia Chapter Division of the American Academy of Emergency Medicine

for Emergency Medicine

Stephanie Burmeister

WestJEM Staff Liaison

Phone: 1-800-884-2236

Email: sales@westjem.org

Sociedad Chileno Medicina Urgencia Thai Association

Substance Use and Addiction Disorders : A Call for Increased Screening and Treatment in the Emergency Department

R. Gentry Wilkerson, MD* Alexis M. LaPietra, DO†

University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland

†

RWJBarnabus Health, Division of Emergency Medicine, West Orange, New Jersey

Section Editor: Mark I. Langdorf, MD, MHPE

Submission history: Submitted October 24, 2024; Revision received October 24, 2024; Accepted October 24, 2024

Electronically published January 20, 2025

Full text available through open access at http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.41808

[West J Emerg Med. 2025;26(1.1)1–2.]

We are very pleased to present the Western Journal of Emergency Medicine (WestJEM) Special Issue on Substance Use and Addiction Disorders. The emergency department (ED) is on the front line in the battle to combat the impact that drugs and alcohol have on the lives of individuals. Each of the articles included in this issue reflects the work and dedication that the authors have devoted to improving the care of patients with substance use and addiction disorders. It is our honor to promote these articles by compiling them under the single banner of a special issue.

According to the 2023 National Survey on Drug Use and Health (NSDUH) 1 released by the US Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration, there are an estimated 48.5 million individuals ≥12 years of age living with a substance use disorder. This is an astounding 17.1% of the population, or more than 1 in every 6 individuals. The NSDUH also found that alcohol use disorder impacts 10.2% of those ≥12. The impact of these disorders leads to high healthcare resource utilization, poor health outcomes, and increased mortality. The average annual number of deaths attributable to excessive alcohol use reached 178,307 during 20202021. 2 Drug overdose deaths have steadily risen every year through 2022 when 107,941 deaths were reported.3 This has largely been driven by opioids. In 2022, there were 82,136 opioid-related overdose deaths.4

The ED bears witness to a multitude of other conditions that are directly related to substance use and addiction disorders. In 2020, there were 11,654 people in the US killed in motor vehicle collisions involving a driver under the influence of alcohol.5 Many more were injured and required care in our EDs. Chronic alcohol use leads to fibrosis and cirrhosis of the liver, which in turn leads to the

development of ascites and esophageal varices. Patients may present critically ill with spontaneous bacterial peritonitis or upper gastrointestinal bleeding. Patients who inject drugs are at risk for development of skin and soft tissue infections, endocarditis, spinal epidural abscesses, HIV, and hepatitis C.

Thanks to pioneers in emergency medicine, our specialty no longer waits for the complications to occur. Rather, we try to reduce the risk of harm related to drug and alcohol use and promote initiation of treatment. In the last decade, it has become common practice for emergency physicians to initiate treatment of opioid use disorder with buprenorphine thanks to the pivotal research showing better retention in treatment when it was initiated in the ED. 6 Many EDs are now using peer recovery coaches and the SBIRT (Screening, Brief Intervention, and Referral to Treatment) process to identify patients with opioid addiction and either initiate treatment in the ED or have a rapid referral to treatment programs.7 In addition to initiating treatment with buprenorphine, EDs are distributing the opioid receptor antagonist, naloxone, to at-risk individuals. The American College of Emergency Physicians has supported increased access to this lifesaving medication since 2015.8

Research is ongoing regarding how to best support patients with substance use and addiction disorders. We hope that this special issue contributes in some way to protecting the health and saving the lives of our patients.

Address for Correspondence: R. Gentry Wilkerson, MD, University of Maryland School of Medicine, Department of Emergency Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201. Email: gwilkerson@som.umaryland.edu.

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. Dr. Wilkerson received research funding from Regeneron Pharmaceuticals, Inc.; Lilly USA, LLC; BioAge Labs, Inc.; Roche Diagnostics; Global Blood Therapeutics, Inc.; Novartis Pharmaceuticals; Egetis Therapeutics AB; EndPoint Health, Inc.; Blade Therapeutics; Janssen R&D LLC; ProvePharma; CSL Behring; Beckton, Dickinson and Company; Pfizer Inc.; Greiner Bio-One North America, Inc.; and the National Foundation of Emergency Medicine (NFEM). He has received research funding from CoapTech, LLC through an NIH/NIDDK grant (R44DK115325). He has received research support in the form of equipment and supplies from Cepheid and Eldon Biologicals A/S. He is a paid consultant for NFEM. The authors disclosed no conflicts of interest.

Copyright: © 2025 Wilkerson et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/ licenses/by/4.0/

REFERENCES

1. Substance Abuse and Mental Health Services Administration. (2024). Key substance use and mental health indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (HHS Publication No. PEP24-07-021, NSDUH Series H-59). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Available at: https:// www.samhsa.gov/data/report/2023-nsduh-annual-national-report.

Accessed September 24, 2024

2. Esser MB, Sherk A, Liu Y, et al. Deaths from Excessive Alcohol Use — United States, 2016–2021. Morb Mortal Wkly Rep. 2024;73(8):154-61.

3. Spencer MR, Garnett MF, Miniño AM. 2024. Drug overdose deaths in the United States, 2002–2022. NCHS Data Brief, no 491. Hyattsville, MD: National Center for Health Statistics. Available at: https://stacks.cdc. gov/view/cdc/135849. Accessed September 24, 2024.

4. The HEALing Communities Study Consortium. Community-based cluster-randomized trial to reduce opioid overdose deaths. N Engl J Med. 2024;391:989-1001.

5. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2020 Data: Alcohol-Impaired Driving (Report No DOT HS 813 294). Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis; April 2022. Available at: https://crashstats.nhtsa.dot.gov/Api/ Public/ViewPublication/813294. Accessed September 23, 2024.

6. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency departmentinitiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-44.

7. Monico LB, Oros M, Smith S, et al. One million screened: scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland. Am J Emerg Medicine. 2020;38(7):1466-9.

8. American College of Emergency Physicians Policy Statement, Naloxone Access and Utilization for Suspected Opioid Overdoses. Available at: https://www.acep.org/siteassets/new-pdfs/policy-statements/naloxoneaccess-and-utilization-for-suspected-opioid-overdoses.pdf. Accessed September 24, 2024.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

ImplementationandEvaluationofaBystander NaloxoneTrainingCourse

ScottG.Weiner,MD,MPH*

ScottA.Goldberg,MD,MPH*

CherylLang,MPH†

MollyJarman,PhD,MPH†

CoryJ.Miller,BS*

SarahLi,BA*

EwelinaW.Stanek,PA-C*

EricGoralnick,MD,MS*

SectionEditor:MarcMartel,MD

*BrighamandWomen’sHospital,DepartmentofEmergencyMedicine, Boston,Massachusetts † BrighamandWomen’sHospital,DepartmentofSurgery,Boston,Massachusetts

Submissionhistory:SubmittedMarch13,2023;RevisionreceivedSeptember26,2023;AcceptedJanuary12,2024

ElectronicallypublishedApril9,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.60409

Introduction: Bystanderprovisionofnaloxoneisakeymodalitytoreduceopioidoverdose-related death.Naloxonetrainingcoursesareavailable,butnostandardizedprogramexists.Aspartofa bystanderempowermentcourse,wecreatedandevaluatedabriefnaloxonetrainingmodule.

Methods: Thiswasaretrospectiveevaluationofanaloxonetrainingcourse,whichwaspairedwithStop theBleedtrainingforhemorrhagecontrolandwasofferedtoadministrativestaffinanofﬁcebuilding. Participantsworkedinanorganizationrelatedtohealthcare,butnonewereclinicians.Thecurriculum includedthefollowingtopics:1)backgroundabouttheopioidepidemic;2)howtorecognizethesignsof anopioidoverdose;3)actionsnottotakewhenencounteringanoverdosevictim;4)thecorrectstepsto takewhenencounteringanoverdosevictim;5)anoverviewofnaloxoneproducts;and6)Good Samaritanprotectionlaws.The20-minutedidacticsectionwasfollowedbyahands-onsessionwith nasalnaloxonekitsandasimulationmannequin.ThecoursewasevaluatedwiththeOpioidOverdose Knowledge(OOKS)andOpioidOverdoseAttitudes(OOAS)scalesfortake-homenaloxonetraining evaluation.WeusedthepairedWilcoxonsigned-ranktesttocomparescorespre-andpost-course.

Results: Twenty-eightparticipantscompletedthecourse.TheOOKS,measuringobjectiveknowledge aboutopioidoverdoseandnaloxone,hadimprovedscoresfromamedianof73.2%(interquartilerange [IQR]68.3%–79.9%)to91.5%(IQR85.4%–95.1%), P < 0.001.ThethreedomainsontheOOASscore alsoshowedstatisticallysigniﬁcantresults.Competencytomanageanoverdoseimprovedona ﬁvepointscalefromamedianof2.5(IQR2.4–2.9)toamedianof3.7(IQR3.5–4.1), P < 0.001.Concerns aboutmanaginganoverdosedecreased(improved)fromamedianof2.3(IQR1.9–2.6)tomedian1.8 (IQR1.5–2.1), P < 0.001.Readinesstointerveneinanopioidoverdoseimprovedfromamedianof4 (IQR3.8–4.2)toamedianof4.2(IQR4–4.2), P < 0.001.

Conclusion: Abriefcoursedesignedtoteachbystandersaboutopioidoverdoseandnaloxonewas feasibleandeffective.Weencouragehospitalsandotherorganizationstouseandpromulgatethis model.Furthermore,wesuggesttheconveningofanationalconsortiumtoachieveconsensuson programcontentanddelivery.[WestJEmergMed.2025;26(1.1)3–7.]

INTRODUCTION

Timeisacriticalcontributingfactorinpatientoutcomes inmanyemergencies.IntheUnitedStates,theaverage responsetimebyemergencymedicalservicestoa9-1-1callis sevenminutes.1 Tobridgethisgap,manyeffortshavebeen launchedtoempowerlaypersons,whoaretypically ﬁrston thescene,tointerveneandemployskillsrangingfrom cardiopulmonaryresuscitation(CPR)andautomated externaldeﬁbrillator(AED)usetobleedingcontrol interventions.2 BasicLifeSupport(BLS)coursecontentis baseduponrigorousandfrequentlyupdatedconsensus(ie, AmericanHeartAssociation[AHA]GuidelinesUpdatefor CPRandEmergencyCardiovascularCare).3,4 Thesecourses aretaughtinastandardizedfashionbytheAHAandthe AmericanRedCross.Likewise,theStoptheBleed(STB) program,anationalinitiativelaunchedin2015focusedon empoweringthepublicandpublicsafetyprofessionalsto recognizeandcontrollife-threateningbleeding,hasseveral typesofcourses,themostprominentbeingtheAmerican CollegeofSurgeons’ (ACS)BasicHemorrhageControl Course(BCon).5,6

WhileCPR,AEDandSTBtrainingfocusonpreventable deaths,anothersigniﬁcantsourceofpreventabledeathsisthe opioidoverdoseepidemic,whichremainsoneofthemost pressingpublichealthissuesofourtime,havingclaimed about1,000,000livesintheUSsince1999.7 Thenumberof overdosedeathshasincreasedgreatlyinrecentyears,with yetanotherrecordnumberin2021,predominantlydueto fentanyl.8 Bystandernaloxoneadministration,whichcanbe usedtoreverseanopioidoverdose,hasbeenintroducedas onepotentialmitigatingfactor.In2018,theUSSurgeon Generalissuedanadvisoryonnaloxoneandopioidoverdose thatencouragescommunitymemberswhocomeintocontact withpeopleatriskforopioidoverdosetoknowhowtouse naloxoneandkeepitwithinreach.9 Likewise,theUS DepartmentofHealthandHumanServices’ overdose preventionstrategyincludesharmreduction,withagoalto widenaccesstoopioidoverdosereversaltreatments.10

UnlikeCPR,thereisnoonestandardizedcoursefor bystandernaloxonetraining.Onlinecoursesareofferedby agenciessuchastheCentersforDiseaseControland Prevention(CDC),11 theAmericanRedCross,12 individual states(eg,Massachusetts13 andNewYork14),andothernonproﬁts(eg,GetNaloxoneNow15).Thecourseslacka standardizedcorecontent,measuresofeffectiveness,oragreedupondeliverymethods(inperson,hybrid,remote,simulation, didactic,etc).Althoughanecdotesexistoflaypersonuse,we havealimitedunderstandingofaneffective,layperson naloxone-empowermentcurriculum,andgapsremainin knowledgeabouttrainingparametersandstrategies.16

Inthisstudy,weevaluatedanoverdose-responsenaloxone trainingprogramadministeredtolaypersons.We emphasizedthestructureandcurriculumofthecourseand evaluatedefﬁcacywithavalidatedscreeningtool.

METHODS

Thenaloxonecoursewasdesignedtobeabrief interventionwith20minutesofdidacticsand20minutesof practicalexperiencewithamannequin.Thecoursewas bundledwiththeACSBConcourseaspartofabystander empowermentprogram.Courseinstructorswerethree board-certifiedemergencyphysicians.Thesessiontookplace ataprofessionalofficebuilding.Althoughtheparticipants workedinanorganizationrelatedtohealthcare,allworked asofficestaffandnonewereclinicians.Twoidenticalsessions wereoffered,andbothtookplaceinJune2018during normalbusinesshours.Participantswerenotcompensated specificallyforparticipatingbutattendedinlieuoftheir normalduties.Weadministeredanonymouspre-andpostcourseevaluations.Theprojectwasdeterminedtonotmeet thecriteriaforhumansubjectresearchbytheMassGeneral BrighamHumanResearchOffice.

Curriculum

Createdbythecourseinstructors,thecurriculumincluded thefollowingtopics:1)backgroundabouttheopioid epidemic;2)howtorecognizethesignsofanopioid overdose;3)actionsnottotakewhenencounteringan overdosevictim;4)thecorrectstepstotakewhen encounteringanoverdosevictim;5)anoverviewofnaloxone products;and6)GoodSamaritanprotectionlaws.Content wascreatedby ﬁrstsearchingforexistingtrainingresources online,includingtrainingmanualsfromthestatesofNew York(https://www.dhses.ny.gov/naloxone-informationﬁrst-responders)andTexas(https://txoti.org),andCanadian provinceManitoba(https://www.gov.mb.ca/health/ publichealth/docs/training_manual_overdose.pdf).This informationwasintegratedwithadditionalcontentfrom courseinstructorexpertiseintoadidacticmodulecontaining 30slides(Appendix1),andparticipantswereprovidedwitha hardcopyoftheslides.Thepracticalmoduleentailedsmall groupsaroundasimulationmannequinwithacourse instructor.Participantswereabletopracticewithtwotypes ofnaloxonekits(pre-packagednasalnaloxonesprayandan autoinjector)onthemannequin.Discussionwasencouraged untilallparticipants’ questionsandconcernswereaddressed.

CourseEvaluation

Toevaluatetheefﬁcacyofthecourse,weusedtheOpioid OverdoseKnowledge(OOKS)andOpioidOverdose Attitudes(OOAS)scalesfortake-homenaloxonetraining evaluation.17 The ﬁrsthalfofthisvalidatedtool(OOKS)asks objectivequestionsaboutopioidoverdosetoevaluatetrainee knowledge,includingindicatorsofopioidoverdose,howto manageanoverdose,themechanismofactionofnaloxone, anditsdurationofaction.Thesecondpart(OOAS)asks questionspertainingtoperceptionsofcompetenciesto manageanopioidoverdose,concernsaboutmanagingan overdose,andreadinesstointerveneinanopioidoverdose.

StatisticalAnalysis

Allparticipantscompletedpre-andpost-evaluationson paperforms.Subjectswereaskedtowritethesamerandom four-digitnumberoneachofthetwoevaluationsforpaired analysispurposes.Responsesweretransferredtoa spreadsheet,andasecondinvestigatorconfirmedthe accuracyofthetranscription.TheOOKSscaleisaseriesof true/falsestatements,andthecorrectanswersweresummed, withatotalpossible41points.Wemodifiedtheoriginal 45-pointversionslightly,asmultiplepointswerepossiblefor severalindividualquestions(eg, “Whatisnaloxoneused for?” and “Howcannaloxonebeadministered?”)andwe countedthemonlyasonepointeach.Therewasalsoachoice of “don’tknow” forseveralquestions,andthatwas consideredanincorrectanswerasindicatedinthescoring instructions.TheOOASscaleis28questionsdividedinto threedomainsandmeasuredona five-pointLikertscale (5 = completelyagreeand1 = completelydisagree). Althoughthepost-testOOKSresultsandoneofthedomains ontheOOASwerenormallydistributedasdeterminedbythe Shapiro-Wilktest,theremainderofresultswerenon-normal. Thus,allresults,includingthescalesoneachdomainofthe OOASandtheoverallscoreontheOOKS,aredescribed withmediansandinterquartilerange(IQR)andcompared withthepairedWilcoxonsigned-ranktest.Weanalyzeddata withJMPv16(JMPStatisticalDiscoveryLLC,Cary.NC).

RESULTS

Twenty-eightparticipantstookthecourse.Allcompleted thepre-testandthepost-test,althoughthreeparticipantsdid notanswerallquestionsonthepre-testOOASscale. Therefore,thecorrespondinganswersinthedomainsfor thesethreeindividualsonthepost-testwerenotincludedin theanalysis.TheOOKS,measuringobjectiveknowledge aboutopioidoverdoseandnaloxone,hadimprovedscores fromamedianof73.2%(IQR68.3%–79.9%)to91.5%(IQR 85.4%–95.1%), P < 0.001.ThethreedomainsontheOOAS scorealsoshowedstatisticallysigniﬁcantresults. Competencytomanageanoverdoseimprovedfroma medianof2.5(IQR2.4–2.9)toamedianof3.7(IQR 3.5–4.1), P < 0.001.Concernsaboutmanaginganoverdose decreased(improved)fromamedianof2.3(IQR1.9–2.6)to median1.8(IQR1.5–2.1), P < 0.001.Readinesstointervene inanopioidoverdoseimprovedfromamedianof4(IQR 3.8–4.2)toamedianof4.2(IQR4–4.2), P < 0.001.

DISCUSSION

Increatingandevaluatinganaloxonetrainingprogram forbystanders,wefoundimprovementinbothsubjective attitudesandobjectiveknowledgeaboutopioidoverdose andnaloxone.Thetrainingisrelativelybrief(lastingunder anhour)andeffective.Wehavesubsequentlytaughtthis curriculumseveraltimestolocalcommunityorganizations, includingthosewhoworkwithpeoplewhousedrugs.

Althoughwedidnotmeasureobjectiveoutcomes subsequently,theconceptofbystanderempowerment, teachingbothnaloxoneandSTBskills,hasbeenwell receivedandrepresentsimportantoutreachfromour hospitaltothelocalcommunity.

Onekeyquestionthatremainsiswhetherthistrainingis necessaryforbystanders.Inourpreviousresearch,wefound that49of50bystanderswereabletocorrectlyadminister naloxoneinasimulatedexperienceonapublicsidewalkwith guidancebyasimulated911dispatcher.18 However,not everyonewillhavetheguidanceofadispatcherwhenusing naloxone,andtheremaybeconfusionabouthowtousethe kitandthetimingofaseconddose(ifneeded)withoutthat assistance.Bystandertrainingmayalsobevaluableasaway tofosterself-efﬁcacy,increasingthelikelihoodthata laypersonwillrecognizeandrespondtoanoverdose.Inour course,wealsocoverwhenbystandersshouldadminister naloxoneanddispelmythsaboutanyharmthatcanbe causedbygivingit,aswellashowtoaccessnaloxone.

Naloxoneforbystandersiscurrentlyavailablevia standingorderinseveralstates,meaningthatindividualscan obtainitfrompharmacieswithoutaprescription.19–22 Standingordersareassociatedwithreductionsinfatal overdosesinthecommunity.23 Thecurrentpackagingof prescriptionnasalnaloxonehasa flapthatopensgivingjustin-time(JIT)instructionstothebystander,butthatmaynot besufficient.TheUSFoodandDrugAdministration(FDA) recentlyapprovedmakingnasalnaloxoneanover-thecountermedication,eventhoughitsbriefingdocument describedseveralcasesofincorrectlyadministerednaloxone, includinganindividualwhodidnotplacethetipofthe dispenserfullyinthenostril,someonewhosqueezedthe devicebutdidnotpushtheplunger,anotherwhoplacedthe deviceupsidedownsothattheplungerwasinthenostril,and severalindividualswhodidnotwait2-3minutesbefore administeringaseconddose.24 WhiletheFDAadvisors votedunanimouslytomakenaloxoneavailablewithouta prescription,25 theseerrorsinadministrationindicate theneedforabystandercoursethatcouldfurther improveoutcomes.

Anotherreasontoteachsuchacourseistoaddressstigma, whichispervasivewhenconsideringopioidusedisorder (OUD).26 Arecentstudyofindividualswhodidnotuseillicit opioidsthemselvesbutknewotherswhodidreportedstigma aboutOUDandmisinformationaboutopioid-related risks.27 Naloxone-basedinterventionscanintroducethe conceptofharmreduction,empowerbystanders,and encourageindividualstocarrynaloxoneincasethey encounteranoverdosevictim.28

Althoughnotapartofourstudy,despitethepositive resultsonourobjectiveandsubjectivetesting,wedo encouragethecreationofstandardizedtraining.TheSTB BConportionofourcoursewascreatedandendorsedby theACS,usingstandardizedcontentandcertiﬁedtrainers.

Asimilarprocesscouldbeusedfornaloxone,eitheraspartof aBLStraining,suchasfromtheAHAorAmericanRed Cross,fromaspecialtysociety,suchastheAmerican AcademyofEmergencyMedicine,theAmericanCollegeof EmergencyPhysicians,ortheAmericanSocietyofAddiction Medicine,orfromanationaladvocacygroupsuchas Shatterproof.Suchbrandingandpromotionmayempower morebystanderstobecometrainedandfurtherreduce stigmaandmisconceptionsaboutOUDamongthe generalpopulation.

WhileCPRtrainingforlaypersonsisthegoldstandard, manygapsinimplementingbystandertrainingremain,and aninvestmentinthestudyoftheeffectivenessoftherelatively simplestepsofnaloxoneadministrationmayhelpuslearn andimprovetechniquesofCPRandSTBtrainingaswell. Forexample,despiteeducationalinitiativesthatbeganinthe 20thcentury,onlyone-thirdofout-of-hospitalcardiacarrest patientsreceivebystanderCPR.Time,location,and durationhaveallbeenperceivedbythepublicasbarriersto CPRclasses.29 BlacksandHispanicsarelesslikelythan WhitestoreceiveCPRathomeorinpublic.30 Inthelast decade,therehavebeenmanyinitiativeswithvariable efficacy,inmostcasesnotmeasured,touseJITtoolslike flashcards,videoortalkingkitstoprovideuserswithrealtimeinstructionsfortheuseofautomatedexternal defibrillatorsorSTBequipment.Whiletheagreementof coursecontentandidentifyingefficacyisa firststep,future workshouldalsofocusondeveloping,trialing,andscaling effectiveJITnaloxone-administrationtools.

LIMITATIONS

Therearelimitationstoourstudy.Wetaughtthiscourse toasmallsampleofadministrativeprofessionalsinasuburb ofMassachusetts,astatewithahighburdenofopioidrelatedoverdose.Itispossiblethatbystandersfromdifferent backgroundsandgeographiclocationswouldhaveanswered thequestionsdifferently.Wealsodidnotcollectany demographicdataaboutourstudyparticipantstoprotect conﬁdentiality.However,thisinformationmighthave determinedthecharacteristicsofindividualswhomaybeneﬁt mostfromthetraining.Thecontentofthepracticalsessionof thecoursewasnotstandardized.Finally,wedidnot measureknowledgeretentionoruseofnaloxonefollowing thecourse.

CONCLUSION

Abriefcoursedesignedtoteachbystandersaboutopioid overdoseandnaloxonewasfeasibleandeffective.We encouragehospitalsandotherorganizationstouseand promulgatethismodel.Furthermore,wesuggestconvening ofanationalconsortiumtoachieveconsensusonprogram content,delivery,andopportunitiesfordevelopmentofjustin-timetoolstoadministernaloxone.

AddressforCorrespondence:ScottG.Weiner,MD,MPH,Brigham andWomen’sHospital,DepartmentofEmergencyMedicine,75 FrancisStreet,NH-226,Boston,MA02115.Email: sweiner@bwh. harvard.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Outsideofthisresearch,ScottG. WeinerissupportedbyNationalInstitutesofHealthgrant5-R01DA044167,theFoundationforOpioidResponseEfforts,andthe ElevanceFoundation.ScottG.Weinerisanadvisorycommittee memberofVertexPharmaceuticals,Inc.andCessation Therapeutics,Inc.Therearenootherconflictsofinterestorsources offundingtodeclare.

REFERENCES

1.MellHK,MummaSN,HiestandB,etal.Emergencymedicalservices responsetimesinrural,suburban,andurbanareas. JAMASurg. 2017;152(10):983–4.

2.FederalEmergencyManagementAgency.Youarethehelpuntil helparrives.Availableat: https://community.fema.gov/ PreparednessCommunity/s/until-help-arrives?language=en_US AccessedAugust20,2023.

3.AmericanHeartAssociation.2020AmericanHeartAssociation GuidelinesforCPRandECC.Availableat: https://cpr.heart.org/en/ resuscitation-science/cpr-and-ecc-guidelines AccessedAugust20,2023.

4.SoarJ,DonninoMW,MaconochieI,etal.2018InternationalConsensus onCardiopulmonaryResuscitationandEmergencyCardiovascular CareSciencewithTreatmentRecommendationssummary. Circulation. 2018;138(23):e714–30.

5.GoralnickE,ChaudharyMA,McCartyJC,etal.Effectivenessof InstructionalInterventionsforHemorrhageControlReadinessfor LaypersonsinthePublicAccessandTourniquetTrainingstudy (PATTS):arandomizedclinicaltrial. JAMASurg. 2018;153(9):791–9.

6.GoolsbyC,JacobsL,HuntRC,etal.StoptheBleedEducation Consortium:educationprogramcontentanddeliveryrecommendations. JTraumaAcuteCareSurg. 2018;84(1):205–10.

7.CentersforDiseaseControlandPrevention.DrugOverdoseDeaths. Availableat: https://www.cdc.gov/drugoverdose/deaths/index.html AccessedAugust20,2023.

8.NationalCenterforHealthStatistics.ProvisionalDrugOverdoseDeath Counts.Availableat: https://www.cdc.gov/nchs/nvss/vsrr/drugoverdose-data.htm.AccessedAugust20,2023.

9.UnitedStatesHealthandHumanServices.U.S.SurgeonGeneral’s AdvisoryonNaloxoneandOpioidOverdose.Availableat: https://www. hhs.gov/surgeongeneral/reports-and-publications/addiction-

and-substance-misuse/advisory-on-naloxone/index.html AccessedAugust20,2023.

10.UnitedStatesHealthandHumanServices.HarmReduction.Available at: https://www.hhs.gov/overdose-prevention/harm-reduction AccessedAugust20,2023.

11.CentersforDiseaseControlandPrevention.NaloxoneTraining. Availableat: https://www.cdc.gov/opioids/naloxone/training/index.html AccessedAugust20,2023.

12.AmericanRedCross.FirstAidforOpioidOverdosesOnlineCourse. Availableat: https://www.redcross.org/take-a-class/opioidoverdose AccessedAugust20,2023.

13.CommonwealthofMassachusetts.Overdose&NaloxoneTraining Resources.Availableat: https://www.mass.gov/service-details/trainingresources.AccessedAugust20,2023.

14.NewYorkState.CommunityCalendarofOpioidOverdoseTrainings. Availableat: https://www.health.ny.gov/diseases/aids/general/ opioid_overdose_prevention/training_calendar.htm AccessedAugust20,2023.

15.GetNaloxoneNow.Availableat: https://www.getnaloxonenow.org/ #home.AccessedAugust20,2023.

16.Moustaqim-BarretteA,DhillonD,NgJ,etal.Take-homenaloxone programsforsuspectedopioidoverdoseincommunitysettings:a scopingumbrellareview. BMCPublicHealth. 2021;21(1):597.

17.WilliamsAV,StrangJ,MarsdenJ.DevelopmentofOpioidOverdose Knowledge(OOKS)andAttitudes(OOAS)scalesfortake-home naloxonetrainingevaluation. DrugAlcoholDepend. 2013;132(1-2):383–6.

18.GoldbergSA,DworkisDA,LiaoVT,etal.Feasibilityofbystander administrationofpublic-accessnaloxoneforopioidoverdose. Prehosp EmergCare. 2018;22(6):788–94.

19.IjiomaSC,FernándezEV,GatewoodSB,etal.Communitypharmacists inVirginiadispensingnaloxoneunderastandingorder:aqualitative study. JAmPharmAssoc(2003). 2021;61(6):753–60.e1.

20.SugarmanOK,BreithauptJ,WangX,etal.Characteristicsandhealth serviceuseofMedicaid-insuredindividuals ﬁllingnaloxoneundera

standingorderinLouisiana. JAmPharmAssoc(2003). 2023;63(3):904–8.e1.

21.AbbasB,MarottaPL,Goddard-EckrichD,etal.Socio-ecologicaland pharmacy-levelfactorsassociatedwithnaloxonestockingatstandingordernaloxonepharmaciesinNewYorkCity. DrugAlcoholDepend. 2021;218:108388.

22.ChatterjeeA,YanS,XuanZ,etal.Broadeningaccesstonaloxone: communitypredictorsofstandingordernaloxonedistributionin Massachusetts. DrugAlcoholDepend. 2022;230:109190.

23.TaylorM,PradhanA,OgandoYM,etal.Impactofthenaloxonestanding orderontrendsinopioidfataloverdose:anecologicalanalysis. AmJ DrugAlcoholAbuse. 2022;48(3):338–46.

24.UnitedStatesFederalDrugAdministration.JointNonprescriptionDrug AdvisoryCommitteeandAnestheticandAnalgesicDrugProducts AdvisoryCommitteeMeeting.2023.Availableat: https://www.fda.gov/ media/165338/download.AccessedAugust20,2023.

25.AntrimA.FDAAdvisoryCommitteesRecommendNaloxoneBe AvailableOTC.2023.Availableat: https://www.pharmacytimes.com/ view/fda-advisory-committees-recommend-naloxone-be-available-otc AccessedAugust20,2023.

26.FomiattiR,FarrugiaA,FraserS,etal.Addictionstigmaandthe productionofimpedimentstotake-homenaloxoneuptake. Health (London). 2022;26(2):139–61.

27.SlocumS,OzgaJE,JoyceR,etal.Ifwebuildit,willtheycome? Perspectivesonpharmacy-basednaloxoneamongfamilyandfriendsof peoplewhouseopioids:amixedmethodsstudy. BMCPublicHealth. 2022;22(1):735.

28.MillerNM,Waterhouse-BradleyB,CampbellC,etal.Howdonaloxonebasedinterventionsworktoreduceoverdosedeaths:arealistreview. HarmReductJ. 2022;19(1):18.

29.McGovernSK,BlewerAL,MurrayA,etal.Characterizingbarriersto CPRtrainingattainmentusingTwitter. Resuscitation. 2018;127:164–7.

30.GarciaRA,SpertusJA,GirotraS,etal.Racialandethnicdifferencesin bystanderCPRforwitnessedcardiacarrest. NEnglJMed. 2022;387(17):1569–78.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

HarmReductionintheField:FirstResponders’ Perceptions ofOpioidOverdoseInterventions

CallanElswickFockele,MD,MS*

TessaFrohe,PhD†

OwenMcBride,MD*

DavidL.Perlmutter,MPH,MSW‡ BrendaGoh,BA‡ GroverWilliams§ CourteneyWettemann§ NathanHolland§ BradFinegood,MA∥

TheaOliphant-Wells,MSW∥ EmilyC.Williams,PhD,MPH‡¶ JennavanDraanen,PhD,MPH‡#

SectionEditor:R.GentryWilkerson,MD

*UniversityofWashington,DepartmentofEmergencyMedicine,Seattle,Washington

† UniversityofWashington,DepartmentofPsychiatryandBehavioralSciences, Seattle,Washington

‡ UniversityofWashington,DepartmentofHealthSystemsandPopulationHealth, Seattle,Washington

§ ResearchwithExpertAdvisorsonDrugUse,Seattle,Washington

∥ PublicHealth – Seattle&KingCounty,Seattle,Washington

¶ HealthServicesResearch&DevelopmentCenterofInnovationforVeteranCenteredandValue-DrivenCare,VeteransAffairsPugetSoundHealthCare System,Seattle,Washington

# UniversityofWashington,DepartmentofChild,Family,andPopulationHealth Nursing,Seattle,Washington

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedOctober24,2023;AcceptedFebruary9,2024

ElectronicallypublishedJune27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18033

Introduction: RecentpolicychangesinWashingtonStatepresentedauniqueopportunitytopair evidence-basedinterventionswith firstresponderservicestocombatincreasingopioidoverdoses. However,littleisknownabouthowtheseinterventionsshouldbeimplemented.Inpartnershipwiththe ResearchwithExpertAdvisorsonDrugUseteam,agroupofacademicallytrainedandcommunitytrainedresearcherswithlivedandlivingexperienceofsubstanceuse,weexaminedfacilitatorsand barrierstoadoptingleave-behindnaloxone, field-basedbuprenorphineinitiation,andHIVandhepatitisC virus(HCV)testingfor firstresponderprograms.

Methods: Ourteamcompletedsemi-structured,qualitativeinterviewswith32 ﬁrstresponders,mobile integratedhealthstaff,andemergencymedicalservices(EMS)leadersinKingCounty,Washington, fromFebruary–May2022.Semi-structuredinterviewswererecorded,transcribed,andcodedusingan integrateddeductiveandinductivethematicanalysisapproachgroundedincommunity-engaged researchprinciples.Wecollecteddatauntilsaturationwasachieved.Datacollectionandanalysiswere informedbytheConsolidatedFrameworkforImplementationResearch.Twoinvestigatorscoded independentlyuntil100%consensuswasreached.

Results: Ourthematicanalysisrevealedseveralperceivedfacilitators(ie,tensionforchange,relative advantage,andcompatibility)andbarriers(ie,limitedadaptability,lackofevidencestrengthandquality, andprohibitivecost)totheadoptionoftheseevidence-basedclinicalinterventionsfor firstresponder systems.Therewaswidespreadsupportforthedistributionofleave-behindnaloxone,althoughfunding wasidentifiedasabarrier.Manybelieved field-basedinitiationofbuprenorphinetreatmentcouldprovide amoreeffectiveresponsetooverdosemanagement,butthereweresignificantconcernsthatthis interventioncouldruncountertotherapidcaremodel.Lastly,participantsworriedthatHIVandHCV testingwasinappropriatefor firstresponderstoconductbutrecommendedthatthisservicebeprovided bymobileintegratedhealthstaff.

Conclusion: TheseresultshaveinformedlocalEMSstrategicplanning,whichwillinformrolloutof processimprovementsinKingCounty,Washington.Futureworkshouldevaluatetheimpactofthese interventionsonthehealthofoverdosesurvivors.[WestJEmergMed.2025;26(1.1)8–17.]

INTRODUCTION

Thepublichealthcrisisofopioidusedisorder(OUD)and opioidoverdosecontinuesunabated,withratescontinuingto rise.1–3 Survivorsofnon-fataloverdosehaveasigniﬁcantly greaterriskofrepeatoverdoseandoverdose-related mortalitywithinthefollowingyear,emphasizingthe importanceof ﬁrstresponderinterventions.4–7 Thesetrends aremirroredlocallyinKingCounty,Washington,wherethe annual9-1-1callvolumeofprobableoverdosesandother opioiduse-relatedincidentsincreasedbymorethan20% from2018–2021.8 Acriticalwindowforinterventionexists, asapproximately40%ofindividualswhodiedofanoverdose in2018hadatleastoneemergencymedicalservices(EMS) encounterduringtheprecedingyear.9

RecentlegislativechangesinWashingtonStatepresented auniqueopportunitytopairevidence-basedinterventions with firstresponderservicestoaddresstheriseinopioid overdoses.Specifically,inFebruary2021,theWashington StateSupremeCourtstruckdownthestatutethatmade possessionofcontrolledsubstancesaclassCfelony.Thestate governmentrespondedbypassingatemporarylawthat expandedtheroleof firstresponders(eg, firefighters, paramedics,andpoliceofficers)toconnectadultsfoundwith smallamountsofcontrolledsubstancestocasemanagement insteadofthecriminallegalsystem.10 In2023thelegislature rolledbacksomeofthesechangeswithapermanentbillthat increasedcriminalpenaltiesfordrugpossessionandpublic useandmadepre-trialdiversiontotreatmentprograms contingentontheprosecutor’sconsent.11

While firstrespondershavehistoricallyprovided importantreferralstocommunityresources,12 such programshavenothistoricallyofferedharm-reduction resourcesortreatmentinitiation.Specifically,therearethree medicalservicesthatareknowntoreduceoverdosedeath andincreaseaccesstocareforpeoplewhousedrugs:leavebehindnaloxone13,14; field-basedinitiationofbuprenorphine treatment14–19;andHIVandhepatitisCvirus(HCV) testing.20 Theseinterventionshavedocumentedefficacyin emergencydepartments13,15 andcommunityclinics14,20 whiledemonstratingpromisingresultsduringbrief encounterswithstreetmedicineteamsandparamedics.16–19 Inparticular,thedistributionofnaloxonekitsiscost effective21,22 andsignificantlyreducesopioid-related fatalities.23–25 BuprenorphinetreatmentforOUDmay decreaseall-causeandopioid-relatedmortalitybyupto 50%,26–29 andHIVandHCVtestingimprovesaccesstocare forpeoplewhousedrugs.30 However,thereisapaucityof literatureontheimplementationofthesethreeevidencebasedprogramsin firstrespondersystems. Groundedincommunityengagedresearch(CEnR) principles,31 ourteampartneredwiththeResearchwith ExpertAdvisorsonDrugUse(READU),agroupof academicallytrainedandcommunity-trainedresearchers withlivedandlivingexperienceofsubstanceuse,toaddress

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Firstrespondershavenothistoricallyoffered harmreductionservicesthatareknownto reduceoverdosedeathandincreaseaccessto careforpeoplewhousedrugs.

Whatwastheresearchquestion?

Whatarethefacilitatorsandbarriersfor ﬁ rst responderstoprovideharmreductionservices inthe ﬁ eld?

Whatwasthemajor ﬁndingofthestudy?

Perceivedfacilitatorsweretensionfor change,relativeadvantage,and compatibility,whilebarrierswerelimited adaptability,lackofevidence,and prohibitivecost.

Howdoesthisimprovepopulationhealth?

Participantsexperiencedatensionforchange andwereactivatedtoimplementleave-behind naloxone, ﬁ eld-basedbuprenorphine,and HIVandhepatitisCvirustesting.

thisgap.Theprimaryobjectivewastoexaminethe facilitatorsandbarrierstotheadoptionofleave-behind naloxone, ﬁeld-basedinitiationofbuprenorphinetreatment, andHIVandHCVtestingfor ﬁrstresponderprograms.The secondaryobjectivewastoinformlocalEMSoverdose responsepolicyandprogramming.

METHODS

StudyDesignandSetting

FromMarch–June2022,weconducted32semi-structured interviewswith ﬁrstresponders,mobilemedicalclinicians, andEMSleadersworkinginKingCounty,Washington.The studywasapprovedbytheUniversityofWashington InstitutionalReviewBoard.

TheoreticalFramework

ThisstudywasinformedbytheConsolidatedFramework forImplementationResearch(CFIR).32 Byprovidinga consistentlyappliedsetofanalyticalcategories,consistingof “constructs” situatedwithin “domains,” theCFIR32 simpliﬁesprocesses,highlightsbarriers,andidentiﬁes potentialareasofimprovement(Figure).Asdescribed below,thisframeworkprovidedthescaffoldingforthe interviewguides,deductivecoding,andthematicanalysis, whichhighlightedvariousconstructsasperceivedfacilitators

1.Intervention Characteristics

2.Outer

3.InnerSetting

EvidenceStrengthandQuality:Stakeholders’perceptionsofthequality andvalidityofevidencesupportingthebeliefthattheinterventionwillhave desiredoutcomes

RelativeAdvantage:Stakeholders’perceptionoftheadvantageof implementingtheinterventionversusanalternativesolution

Adaptability:Thedegreetowhichaninterventioncanbeadapted,tailored, refined,orreinventedtomeetlocalneeds

Cost:Costsoftheinterventionandcostsassociatedwithimplementingthe interventionincludinginvestment,supply,andopportunitycosts

TensionforChange:Thedegreetowhichstakeholdersperceivethecurrent situationasintolerableorneedingchange

Compatibility:Thedegreeoftangiblefitbetweenmeaningandvalues attachedtotheinterventionbyinvolvedindividuals,howthosealignwith individuals’ownnorms,values,andperceivedrisksandneeds,andhowthe interventionfitswithexistingworkflowsandsystems

Figure. AdaptedConsolidatedFrameworkforImplementationResearch(CFIR)withnumbereddomainsandselectedconstructs.

(ie,tensionforchange,relativeadvantage,compatibility) andbarriers(ie,adaptability,evidencestrengthandquality, andcost).

ReﬂexivityandPartnership

Ourstudyteamwascomposedofharmreductionists, includingbothacademicallytrainedresearcherswith advanceddegreesinpublichealth,psychology,and medicine,andcommunity-trainedresearcherswithlivedand livingexperienceofdruguseandEMSsysteminvolvement. Together,weembracedCEnRprinciples,31 practiced reﬂexivity,33 andcenteredtheperspectivesofpeoplewhouse drugsinthestudy’sdesign,execution,andanalyses.Priorto startingdatacollection,weengagedinbidirectionaltraining duringwhichcommunity-trainedREADUmembers educatedtheacademicallytrainedresearchersoneffective outreachstrategiesandexperienceswithpaststudies,while academicallytrainedresearcherssharedknowledgeabout qualitativestudydesignandanalysis.

ParticipantRecruitment

Participantswererecruitedthroughconvenienceand snowballsampling.Weemailedrecruitmentmaterialsto leadersandadministratorsatavarietyof firstresponder agenciesinKingCountytodisseminateinformationto potentialparticipants,includingparamedics, firefighters, policeofficers,mobileintegratedhealthstaff(ie,corespondingsocialworkersand firefightersengagedin communityparamedicine),andmobilemedicalclinicians (ie,socialworkers,nurses,physicianassistants,andnurse practitionersperformingstreetoutreach).Interested individualscontactedthestudyteamthroughourstudy phoneoremail,andtheywerescreenedforeligibility. Inclusioncriteriaincludedexperienceworkingasa first responder,amobilemedicalclinician,orinamanagement/ leadershippositionina firstresponderorganizationinKing County;beingover18yearsofage;andspeakingEnglish.

DataCollection

Demographicinformationcollectedfromparticipants includedage,gender,raceand/orethnicity,employment,and highestlevelofeducationalattainment.Separatebutrelated interviewguidesinformedbytheCFIR32 frameworkwere developedfor firstresponders,mobilemedicalclinicians,and EMSleaders.Topicscoveredintheinterviewsincluded participants’ perceivedrolewithintheopioidepidemic; perceptionsofservicesprovidedtopeoplewhousedrugs;and theperceivedfeasibility,acceptance,andappropriatenessof leave-behindnaloxone, field-initiatedbuprenorphine,and HIVandHCVtesting.Theinterviewguideswereiteratively refined,andthe finalguidesareincludedasanappendix.An academicallytrainedresearcherwithpriorexperiencein qualitativemethodswaspairedwithacommunitytrained READUmembertoconducteachinterview.

ThematicAnalysis

Weusedanintegrateddeductiveandinductivethematic approach34,35 toanalysis.Oncetheinitialinterviewswere completed,wefamiliarizedourselveswiththedata,reviewedthe transcriptsforaccuracy,andnotedinitialimpressionstogether. Wegroupedemergentobservationsintoinductivecodesand situatedtheminourpreliminarycodebookwiththepre-existing deductiveCFIRcodes.32 Weappliedthecodebooktoasingle interviewtranscript,engagedinline-by-linecodingasagroup, andreconciledanydisagreementsincodeapplicationsto ﬁnalizethecodebook.Individualteammembersthenprimarily appliedtherevisedcodebooktoeachtranscript,andanother conductedsecondarycoding,addressinganydifferences.

Subsequentsemi-structuredinterviewswereconducted untilthematicsaturationwasreached.Interviewswere recorded,transcribed,deidentiﬁed,uploadedtothe qualitativedatamanagementsoftwareDedoose (SocioCulturalResearchConsultants,LLC,Manhattan Beach,CA),andcodeddeductivelyusingexistingCFIR codes32 andinductivelyusingcodescreatedfromreviewinga 5.Process

sampleoftranscripts.36 Wesummarizedcodeddatato identifybarriersandfacilitatorstoadoptingleavebehind naloxone, ﬁeld-basedbuprenorphineinitiation,andHIVand HCVtestingfor ﬁrstresponderprograms,andweextracted prototypicalexamplesofeach.

RESULTS

ParticipantDemographics

Weinterviewed32 firstresponders,mobilemedical clinicians,andEMSleaderswhoworkedinsevendifferent citieslocatedinKingCounty,Washington(Table1). ParticipantsincludedBasicLifeSupportprofessionals (ie, firefighter/emergencymedicaltechnicians),Advanced LifeSupportprofessionals(ie,paramedics),policeofficers, nurses,andadvancedregisterednursepractitioners,social workers,andEMSleaders.Ofthe firstresponders interviewed,19(59%)hadbeenintheircurrentroleformore than10years.Participantswere31.3%femaleand12.5% racially/ethnicallydiverse,andmostwereabovetheageof36 withatleastsomecollegeeducation.

QualitativeResults

ThroughthelensoftheCFIRframework,32 ourthematic analysisrevealedseveralperceivedfacilitators(ie,tensionfor change,relativeadvantage,andcompatibility)andbarriers (ie,limitedadaptability,lackofevidencestrengthand quality,andprohibitivecost)totheadoptionofthree evidence-basedclinicalinterventionsfor ﬁrstresponder systems:1)leavebehindnaloxone;2) ﬁeld-basedinitiationof buprenorphinetreatment;and3)HIVandHCVtesting.

Leave-behindNaloxone

Therewaswidespreadsupportforthedistributionof leave-behindnaloxonewithmanyacknowledgingatension forchangeand ﬁndingtheinterventionrelatively advantageousandcompatiblewithinexistingsystems (Table2).Manyintervieweesrecognizedthatnaloxoneisa safe,easy-to-use,indispensablemedicationthatshouldbe accessibletopatients,theirlovedones,andothercommunity responders.Implementationofleave-behindnaloxonewas alsolargelythoughttobefeasiblewithseveralinterviewees explainingthatdistributioncouldbeeffortlesslyintegrated intocurrentworkﬂows.

Asmallergroupofindividualsexpressedconcernabout potentialbarriers,particularlylimitedadaptability,lackof evidencestrengthandquality,andprohibitivecost.Some policeofﬁcersthoughtthatnaloxonedistributionmay encourageunsafebehaviors(eg,usinglargeramountsor morepotentsubstances)andfeltthatitwasincongruouswith theirdepartments’ currentapproachtocontrollingdruguse throughlegalpenaltiesandincarceration.Otherservice professionalsworriedthatincreasedaccesstonaloxone wouldleadtocommunitymembers,ratherthan ﬁrst responders,managingmoreoverdoseresponsesand

Table1. Interviewees’ demographicinformation.

Agen(%)

20–252(6.3%)

26–355(15.6%)

36–4511(34.4%)

46–556(18.8%)

56–658(25%)

Gendern(%)

Male20(62.5%)

Female10(31.3%)

Trans,non-binary,orgendernon-conforming2(6.3%)

Raceand/orethnicityn(%)

White28(87.5%)

AsianorPaciﬁcIslander2(6.3%)

Hispanic1(3.1%)

Mixedrace1(3.1%)

Employmentn(%)

BasicLifeSupportprofessionals (ie, ﬁreﬁghter/emergencymedical technicians) 8(25%)

AdvancedLifeSupportprofessionals (ie,paramedics) 6(18.8%)

Policeofﬁcers5(15.6%)

Nursesandadvancedregistered nursepractitioners 3(9.4%)

Socialworkers5(15.6%)

Emergencymedicalservicesleaders5(15.6%)

Numberofyearsincurrentrolen(%) <12(6.3%)

1–48(25%)

5–93(9.4%)

10–198(25%) >2011(34.4%)

Highestlevelofeducationalattainmentn(%)

Associate’sdegree8(25%)

Bachelor’sdegree8(25%)

Master’sdegree10(31.3%)

Doctoraldegree2(6.3%)

Unspeciﬁed4(12.5%)

consequentlydecreasingthelikelihoodofconnectingpeople totreatmentandotherresources.Lastly,severalinterviewees inleadershipormanagementroleswereskepticalaboutthe relativebeneﬁtofnaloxone,explainingthattheybelieved thereoughttobemoreevidenceontheefﬁcacyofleavebehindnaloxoneprograms.Theyalsoworriedaboutthe resourcesandtrainingrequiredforimplementation.

Table2. Interviewees’ perceivedfacilitatorsandbarrierstoimplementingaleave-behindnaloxoneprogram.

Facilitators

Tensionforchange “AndIthink,yes,certainlythe ﬁredepartmentshouldplayaroleinhavingaccesstothatandbeing abletohanditoutandprovidingeducationonhowtouseitandwhentouseit.” Paramedic(ID#25)

Relativeadvantage “Ithinkthatnaloxonesare[a]lifesavingintervention,andit’srelativelyeasyforpeopletoadministerto theirfriendsorbystanderscanadministertopeopletheydon’tknow.So,Idothinknaloxoneisvery importantanditshouldbeoutthereandthereshouldbeaccesstoit.Andusleavingitbehindwith people,Ithinkisagoodidea.” Paramedic(ID#7)

Compatibility “Ithinkthat’sprobablytheeasiestone WecouldabsolutelygettheNarcan Firstresponders deﬁnitelycanprovide[those]asanintervention.” Mobileintegratedhealthsocialworker(ID#20)

Barriers

Limitedadaptability “Ifeellikeit’dbeapsychologicalthingforofficers,especiallyofficerswho’vebeenaroundfor10plus years,whereweusedtoarrestdrugdealersandputtheminjail.Andnowwe’reignoringthecrimes they’recommittingandwe’regivingthemnaloxonesothattheycanfurtherjustcontinuetousedrugs. So,Icanseesomeonewhoismaybenotlookingatthefullpictureorjusthastheirpersonalbeliefs.” Policeofficer(ID#1)

Lackofevidencestrength andquality “Iworrythatwe’rejustput[ting]morepeopleinwithdrawalandsortofmiss[ing]theopportunitiestodo somethingaboutit.” Intervieweeinleadershipormanagementrole(ID#28)

Prohibitivecost “ButIalsohavesomeskepticismthatsortofjustthrowingoutnaloxonekitsisgonnamakeabig difference.I’mnotopposedtoit,butitdoesrequiremoreeffortandtimeandenergy,andthere’sacost toit.Andquitefrankly,wehave[a]limitedbudget,andso,who’sgoingtopayforthosethings?Idon’t know.SoI’mmeasuredinmysupportforthatprogram,butifthere’sevidencethatitsaveslives,then wewillworktowardsthat.” Intervieweeinleadershipormanagementrole(ID#27)

Field-basedInitiationofBuprenorphineTreatment

Despitehavinglessfamiliaritywiththemedication comparedtonaloxone,mostintervieweesrecognizeda tensionforchangeandapprovedoftheimplementationof field-basedinitiationofbuprenorphinetreatment, consideringitevidence-based,appropriate,andrelatively advantageousfortheirsettings(Table3).Manyfelt unpreparedtoaddresswithdrawal,particularlywhena patient’soverdosemayhavebeenfullyreversedwith bystandernaloxone,butbuprenorphinewasseenasa “destigmatizing” toolthatrelievessymptoms,demonstrates compassion,andbuildstrustbetweenpatientsand first responders.Additionally,participantsdescribedhowthe recentuptickinoverdoseresponses,occasionallywiththe sameindividuals,ledtoburnoutandadesiretoaddressthe upstreamcausesofsubstanceuse.Severalhighlightedhow field-basedinitiationofbuprenorphinetreatmentcould bridgevulnerableindividualstoongoingtreatment, potentiallypreventingfutureoverdoses,decreasingoverall callvolumes,andsavinglives.

Thoseopposedwerelargelyconcernedwiththis intervention’slimited adaptability totherapidservice deliverymodelofemergencyservices,emphasizingthatthe timeneededfortheinterventionmayoverburdenanalready overwhelmedsystem.However,otherssuggestedthatthe deploymentofspecializedteams(eg,mobileintegrated healthormobilemedicalclinicteams)dedicatedtotreating thispatientpopulationmaybeawaytooffsetthesedemands. Finally,somepoliceofﬁcersworriedaboutthe evidence

strengthandquality ofbuprenorphine,speculatingthatit couldbedivertedfornon-prescribeduseandcould encourageongoingriskybehaviorsbycurbing withdrawalsymptoms.

HIVandHepatitisCVirusTesting

Intervieweesobservedthetensionforchangeintheir organizationsandgenerallysupportedincreasingaccessto HIVandHCVtesting(Table4).Somefeltthat ﬁrst responderencounterscouldserveasrelativelyadvantageous opportunitiestoengageindividualswhomaynotfeel comfortableseekingcareinmoretraditionalsettings. ProvidingHIVandHCVtestinginatrauma-informed mannerwasseentoincreaseeducationaroundprevention andimprovelinkagetocare.

Many,however,wereconcernedabouttheadaptability, appropriateness,andfeasibilityofHIVandHCVtesting duringanEMSresponse.Someworriedthatitwouldbe inconsistentwiththerapidservicedeliverymodelof emergencyservicessincepoint-of-caretestingtakesatleast 20minutestocomplete.37,38 Othersvoicedthattestingmay feelcompulsoryandcoerciveifcompletedimmediatelyafter anunnervingoverdoseevent.Like field-based buprenorphinestarts,someintervieweesalternatively proposedhaving firstrespondershandoffthesepatientstoa specializedteamthatwouldhavemoretimetoconductthe tests,providetheappropriatecounseling,andarrange follow-upasneededforconfirmatorydiagnosis andtreatment.

Table3. Interviewees’ perceivedfacilitatorsandbarriersto ﬁeld-basedinitiationofbuprenorphinetreatment.

Facilitators

Tensionforchange “Ithinktheopioidissuethatwehaveinourkindofcityrightnow,it’sbigandittakesabigtollon people.AndIthinkthatifthereisevidencethatshowsthatSuboxoneorbuprenorphinecanhelp,and ::: especiallyifwe’refollowinginthefootstepsofanotheragencyoragenciesthathaveuseditand havesomedataonwhatworksandwhatdoesn’t,thenIwouldbeallforit.” Mobilemedical nurse(ID#15)

“Suboxoneisgoodstuff.Ifwe’retrulytryingtohelppeopletransitionoutofaddiction,it’sagreattoolto helpmanagewithdrawals.Asfarasinthe ﬁeld,Ithinkifwecouldprovidethemaccesstoit, absolutely,Iwouldbe100%behindthat.” Fireﬁghter(ID#4)

“IthinkEMSisoftenthe ﬁrstinteractionofaprettytraumaticchainofeventsleadingtotheED.Andso, Ithinkifthatengagementwerepositive,there’dbelesshesitationtocall911,numberone,for overdose.Andthennumbertwo,everychancewecangivesomeonetodecreaseorstoptheiropioid useiswellworthit.Itfeelsalittlemorelikewe’remakingadifferencethangivingthenaloxone,the Narcan,'causehereit’slike, ‘Thisisgoingtohelpyouweanyourbodyoffthisstuff.’" Mobile medicalsocialworker(ID#11)

Relativeadvantage

“Iwouldsay,absolutelyanywaythatwecanexpandourreachtoourcommunityandgetthemmore support,andforaddictionsandforrecovery,Iwouldthinkwouldbeoptimal.AndIthinkthatthe ﬁre serviceisagreatwaytoallowthattohappen ::: I’minfullsupport.Ithinkthatwouldbeadvantageous inourcommunity.” Paramedic(ID#25)

“Anditseemsfarmoreofaviableoptiontomethantheleaveathome[naloxone].Sothe[leave behindnaloxone]wasjustgonnasolvetheproblemintheminute.Butitdoesnottakeawaythenext problem,whichisIneedmore,whereasbuprenorphinedoesaddressthat Butthebetteroption [is]tohowtogetthatmedicinetopeople.” Intervieweeinleadershipormanagementrole(ID#28) Barriers

Limitedadaptability “Thatwouldbepotentiallygood ::: [But]we’re[a]busyunit ::: howmuchoutofservicetimewould thataddtotheunittodothat?” Paramedic(ID#22)

Lackofevidencestrength andquality

“We’vemadelifeeasierforallthese[peoplewhousedrugs]outinSeattle,andithasn’tmadethings better.It’sactuallymadethingsworse.Imean,we’relookingatlike270deathssofarjustinthis ﬁrst quarter.Thatisfourtimesmorethanthreeorfouryearsago.So,Idon’tknowifgivingsuboxoneis actuallyhelpful.” Policeofﬁcer(ID#1)

EMS,emergencymedicalservices; ED,emergencydepartment.

Table4. Interviewees’ perceivedfacilitatorsandbarrierstoHIVandhepatitsCvirustesting.

Facilitators

Tensionforchange

Relativeadvantage

Barriers

“Thisisoneofthosethingsthatisinourrealmof responsibility.Ourprimarygoalistohelppeoplewith what’shappeningrightnow,butifwecanalsohelpthemoutwithlike, ‘Well,whatisthenextstepfor you?’” Mobileintegratedhealthsocialworker(ID#17)

“Hundredpercentliketheideaofbeingabletohaveanagencythathasacontractthatthisiswhatthey do.Yougoout,andyouprovidesomebodyanHIVtest.Wehavepeoplethatarespeciallytrainedtodeal withalltheramificationsofsomebodywho findsouttheyhaveHIV,'causethat’sgonnabeahorrible feeling.” Firefighter(ID#4)

Limitedadaptability “Thatwouldn’tbesomethingusefulfor firstrespondersbecauseourpriorityisnotnecessarilytestingand tryingtodiagnosewhetherindividualshave[a]specificdisease.” Firefighter(ID#2) “Ijustthinkthat’dbehorribletodotosomebody LikeHIVorhepatitisC,likethosearehugethings.So, youjustdon’twanttojustdropabombonsomebodyontopofthembeing Duringadrugoverdose, forexample.” Paramedic(ID#25)

DISCUSSION

Workingonthefrontlinesoftheopioidepidemic, ﬁrst responders,mobilemedicalclinicians,andEMSleadersare confrontedwithskyrocketingoverdoseresponses.Many

wanttoimprovethecareofpatientswhousedrugs,beyond acuteoverdosereversal,butfeeluncertainabouthowto proceed.Peoplewhousedrugshavealsoexpressedaneedfor improvedcarewithmanyrefusingEMStransportfollowing

overdoseduetolawenforcement’spresenceatoverdose scenes, 39 unmanagedwithdrawalsymptoms,andanticipated stigmatizingtreatmentbyEMSandemergencyclinicians.40 OurthematicanalysisinformedbytheCFIRframework32 identifiedseveralperceivedfacilitators(ie,tensionfor change,relativeadvantage,andcompatibility)andbarriers (ie,limitedadaptability,lackofevidencestrengthand quality,andprohibitivecost)totheadoptionofthree evidence-basedclinicalinterventionsfor firstresponder systems:1)leave-behindnaloxone;2) field-basedinitiationof buprenorphinetreatment;and3)HIVandHCVtesting. However,therearefewexamplesofimplementingthese evidence-basedinterventionsin firstrespondersystemswith onenarrativereview findingonly27programsoutofnearly 22,000EMSagenciesnationallydescribedintheliterature, withmanyprovidingnaloxonedistributionandcommunity referralswhilefewfacilitatedlinkagetomedications forOUD.41

Manyrecognizedthetensionforchangeintheir communityandtherelativeadvantageofdistributing naloxonekitsandtreatingOUDwithbuprenorphineinthe ﬁeld.Leave-behindnaloxoneisacost-effective,21,22 widely accepted42–44 toolthatreducesopioidoverdose-related mortality45,46 anddoesnotincreaseriskydruguse behavior.47 ExistingEMSprogramsdistributingnaloxone kitsdemonstratedfeasibility48 andincreasedconnectionto otherresources.49 Mostintervieweesbelievedleave-behind naloxonewascompatiblewithandcouldbeeasilyintegrated intotheirworkﬂows,yetseveralhighlightedtheimportance ofsecuringsustainablefundingtoaddresscostsandreceiving additionaltrainingtoaddresstheperceivedlackofevidence strengthandqualitybeforeimplementation.Participants weresimilarlyenthusiasticabouttheprospectoftreating opioidwithdrawalandOUDwithbuprenorphine.In additiontoaninitialcaseseriesdescribingtreating withdrawalfromnaloxoneadministrationwith buprenorphine,18 apilotstudyexaminingprehospital buprenorphinetreatmentforOUDshowed50%retentionin treatmentatsevendaysand36%in30days.19

Notably,participantsworkinginlawenforcementwere moreskepticalofharmreductionthanthoseemployedin healthcareandsocialservices.Someexpressedfrustration withrecentlegislationthatcurtailedcriminalpenaltiesfor drugpossessionandpublicuse.Otherlawenforcement officersexpressedsentimentssimilartothoseofhealthcare andsocialservicesworkersbutquestionedwhattheirrolein addressingtheopioidepidemiccouldbeunderthenewlaws. Importantly,policeofficersstillregularlyrespondtomedical emergenciesinvolvingdruguse,includingoverdoses, highlightingtheurgentneedfortargetededucationonhowto usetheseevidence-basedinterventionseffectively inthe field.

Lastly,themostdiscussedbarriertoallthree interventions,particularly ﬁeld-basedinitiationof

buprenorphineandHIVandHCVtesting,wasafeelingfrom frontlineprofessionalsthatimplementationhadlimited adaptabilitytotherapidservicedeliverymodelofemergency services.However,othersrecommendedeitherdeployinga specializedteamtothesceneortransportingthepatienttoa diversionfacilitythatcouldprovidewraparoundservices. Localmobilemedicalclinicteamshavesuccessfully integratedharmreductionservicesintotheircareofthose experiencinghomelessness,50 andthecreationofmobile integratedhealthresponseunitshaveexpandedcase managementandreferralsthroughmultidisciplinary collaborationsin ﬁredepartments.51 Withlonger dispatchtimeandtheabilitytodolongitudinalfollow-up, theseteamsmaybewellsuitedtoprovide post-overdosecare.

ThePhiladelphiaFireDepartmenthasanalternative responseunit(“AR-2”)equippedwithAdvancedLife Supportcapabilities,whichislocatedinanareaheavily impactedbyopioidoverdoses.Itrespondstothose resuscitatedwithnaloxonebutwhorefusetransportationto thehospital,andearlydatademonstratesthat84%of patientsacceptedservices,includingtreatmentfacility placement,resources,and/ornaloxonekits.52 Diversion facilitiesofferinglow-barrieraccesstotreatmentandother servicescouldalsooperateasanalternativetoaprolonged EMSresponseoremergencydepartmentvisits;infact,a formerhospitalfacilityinColumbus,Ohio,nowequipped with60bedsdedicatedtoaddictionstabilizationserves astheprimarypost-overdosereceivingcenterfor individualsseekingtreatmentanddeemedmedically stablebyEMS.53

LIMITATIONS

Ourobjectiveinthisstudywastoexaminethefacilitators andbarrierstotheadoptionofleave-behindnaloxone, fieldbasedinitiationofbuprenorphinetreatment,andHIVand HCVtestingfor firstresponderprograms.However,the resultsmayonlybeapplicabletothegeographiclocationof theinterviewees,whichincluded firstresponders,mobile medicalclinicians,andEMSleadersworkinginKing County,Washington.Racialandethnicminoritieswere notablypoorlyrepresentedinourstudy.Becausethereisno publiclyavailabledataonthedemographicinformationof EMSprofessionalslocally,wewereunabletoassesswhether oursamplewasrepresentative.Ourconvenienceand snowballsamplingmayhavealsointroducedbias.Most participantsdescribedbeingintheircurrentroleformore than10years,whichislikelymuchhigherthanthegeneral firstresponderpopulation.Finally,wedidnottrackthe decline-to-beinterviewedrate.

CONCLUSION

Withoutthetoolstoaddresstheuptickinopioid overdoses, ﬁrstresponders,mobilemedicalclinicians,and

EMSleadersinKingCountyexperiencedatensionfor changeandarenowactivatedtoimplementleave-behind naloxone, ﬁeld-basedinitiationofbuprenorphinetreatment, andHIVandHCVtestingthroughnewEMSprotocols, post-overdoseresponseteams,anddiversionfacilities.Inthis studywetookateam-basedapproachandcenteredthe perspectivesofpeoplewithlivedandlivingexperienceof drugusetoensurethatthisresearchledtoaction.Members ofREADUhighlightedourwork’srelevancetothe communityandframedthese ﬁndingstoinformpolicy, particularlywiththerecentchangesinWashington Statelegislation.Futureworksshouldevaluatethe impactoftheseinterventionsonthehealthof overdosesurvivors.

AddressforCorrespondence:CallanElswickFockele,MD,MS, UniversityofWashington,DepartmentofEmergencyMedicine,325 9th Ave.,Box359702,Seattle,WA98109.Email: cfockele@uw.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisstudywassupportedbya UniversityofWashingtonImplementationScienceProgramPilot Grant(PIvanDraanen).Therearenootherconflictsofinterestor sourcesoffundingtodeclare.

REFERENCES

1.KingCountyMedicalExaminer.Overdosedeaths.2022.Availableat: https://kingcounty.gov/depts/health/examiner/services/reports-data/ overdose.aspx.AccessedFebruary23,2023.

2.AdministrationforStrategicPreparedness&Response.Renewalof determinationthatapublichealthemergencyexists.2022.Availableat: https://aspr.hhs.gov/legal/PHE/Pages/Opioids-29Sept22.aspx AccessedonFebruary23,2023.

3.CentersforDiseaseControlandPrevention:NationalCenterforHealth Statistics.DrugoverdosedeathsintheU.S.top100,000annually.2021. Availableat: https://www.cdc.gov/nchs/pressroom/nchs_press_ releases/2021/20211117.htm.AccessedFebruary23,2023.

4.BarefootEH,CyrJM,BriceJH,etal.Opportunitiesforemergency medicalservicesinterventiontopreventopioidoverdosemortality. PrehospEmergCare. 2021;25(2):182–90.

5.OlfsonM,WallM,WangS,etal.Risksoffatalopioidoverdoseduringthe ﬁrstyearfollowingnonfataloverdose. DrugAlcoholDepend. 2018;190:112–9.

6.StoovéMA,DietzePM,JolleyD.Overdosedeathsfollowingprevious non-fatalheroinoverdose:recordlinkageofambulanceattendanceand deathregistrydata. DrugAlcoholRev. 2009;28(4):347–52.

7.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

8.PublicHealth Seattle&KingCounty.Non-fataloverdose.2022. Availableat: https://kingcounty.gov/depts/health/overdose-prevention/ non-fatal.aspx.AccessedFebruary23,2023.

9.CarhartE.Abstractsforthe2020NAEMSPScientiﬁcAssembly. PrehospEmergCare. 2019;24(1):100–56.

10.WashingtonStateLegislature.SB5476–2021-22:addressingtheState v.Blakedecision.2021.Availableat: https://app.leg.wa.gov/ billsummary?BillNumber=5476&Initiative=false&Year=2021 AccessedonFebruary23,2023.

11.WashingtonStateLegislature.SB5536–2023-24:Concerning controlledsubstances,counterfeitsubstances,andlegenddrug possessionandtreatment.2023.Availableat: https://app.leg.wa.gov/ billsummary?BillNumber=5536&Year=2023&Initiative=False AccessedonOctober3,2023.

12.MarrenR.REACH/EMSpilotstudydesign:vulnerablepopulations strategicinitiative(VPSI)ofKingCountyEmergencyMedicalServicesin partnershipwithREACHandPugetSoundandRentonRegionalFire Authorities.2018.Availableat:~https://kingcounty.gov/depts/health/ emergency-medical-services/vulnerable-populations/~/media/depts/ health/emergency-medical-services/documents/vulnerablepopulations/reach-ems-pilot-study.ashx AccessedonFebruary23,2023.

13.SamuelsEA,DwyerK,MelloMJ,etal.Emergencydepartment-based opioidharmreduction:movingphysiciansfromwillingtodoing. AcadEmergMed. 2016;23(4):455–65.

14.WinhusenT,WalleyA,FanucchiLC,etal.TheOpioid-overdose ReductionContinuumofCareApproach(ORCCA):evidence-based practicesintheHEALingCommunitiesStudy. DrugAlcoholDepend. 2020;217:108325.

15.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence: arandomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

16.CarrollGG,WassermanDD,ShahAA,etal.Buprenorphine ﬁeld initiationofrescuetreatmentbyemergencyservices (BupeFIRSTEMS):acaseseries. PrehospEmergCare. 2021;25(2):289–93.

17.CarterJ,ZevinB,LumPJ.Lowbarrierbuprenorphinetreatmentfor personsexperiencinghomelessnessandinjectingheroininSan Francisco. AddictSciClinPract. 2019;14(1):20.

18.HernHG,GoldsteinD,KalminM,etal.Prehospitalinitiationof buprenorphinetreatmentforopioidusedisorderbyparamedics. PrehospEmergCare. 2022;26(6):811–7.

19.HernHG,LaraV,GoldsteinD,etal.Prehospitalbuprenorphine treatmentforopioidusedisorderbyparamedics: ﬁrstyear resultsoftheEMSbuprenorphineusepilot. PrehospEmergCare. 2023;27(3):334–42.

20.CalinR,MassariV,PialouxG,etal.Acceptabilityofon-siterapidHIV/ HBV/HCVtestingandHBVvaccinationamongthreeat-riskpopulations

indistinctcommunity-healthcareoutreachcentres:theANRS-SHS154 CUBEstudy. BMCInfectDis. 2020;20(1):851.

21.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributing naloxonetoheroinusersforlayoverdosereversal. AnnInternMed. 2013;158(1):1–9.

22.UyeiJ,FiellinDA,BuchelliM,etal.Effectsofnaloxonedistributionalone orincombinationwithaddictiontreatmentwithorwithoutpre-exposure prophylaxisforHIVpreventioninpeoplewhoinjectdrugs: acost-effectivenessmodellingstudy. LancetPublicHealth. 2017;2(3):e133–40.

23.BirdSMandMcAuleyA.Scotland’sNationalNaloxoneProgramme. Lancet. 2019;393(10169):316–8.

24.BirdSM,McAuleyA,PerryS,etal.EffectivenessofScotland’sNational NaloxoneProgrammeforreducingopioid-relateddeaths:abefore (2006-10)versusafter(2011-13)comparison. Addiction. 2016;111(5):883–91.

25.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxone distributioninMassachusetts:interruptedtimeseriesanalysis. BMJ. 2013;346:f174.

26.LarochelleMR,BernsonD,LandT,etal.Medicationforopioiduse disorderafternonfatalopioidoverdoseandassociationwithmortality:a cohortstudy. AnnInternMed. 2018;169(3):137–45.

27.PearceLA,MinJE,PiskeM,etal.Opioidagonisttreatment andriskofmortalityduringopioidoverdosepublichealthemergency: populationbasedretrospectivecohortstudy. BMJ. 2020;368:m772.

28.SordoL,BarrioG,BravoMJ,etal.Mortalityriskduringandafteropioid substitutiontreatment:systematicreviewandmeta-analysisofcohort studies. BMJ. 2017;357:j1550.

29.WakemanSE,LarochelleMR,AmeliO,etal.Comparativeeffectiveness ofdifferenttreatmentpathwaysforopioidusedisorder. JAMANetw Open. 2020;3(2):e1920622.

30.SimeoneCA,SealSM,SavageC.ImplementingHIVtestingin substanceusetreatmentprograms:asystematicreview. JAssoc NursesAIDSCare. 2017;28(2):199–215.

31.KeyKD,Furr-HoldenD,LewisEY,etal.Thecontinuumof communityengagementinresearch:aroadmapforunderstandingand assessingprogress. ProgCommunityHealthPartnersh. 2019;13(4):427–34.

32.DamschroderLJ,AronDC,KeithRE,etal.Fosteringimplementationof healthservicesresearch ﬁndingsintopractice:aconsolidated frameworkforadvancingimplementationscience. ImplementSci. 2009;4:50.

33.JonesRG.Puttingprivilegeintopracticethrough “intersectional reﬂexivity:” ruminations,interventions,andpossibilities. Reﬂections: NarrativesofProfessionalHelping. 2010;16(1):122–5.

34.BraunVandClarkeV.Usingthematicanalysisinpsychology. QualRes Psychol. 2006;3(2):77–101.

35.BraunVandClarkeV.Thematicanalysis. JPositPsychol. 2017;12(3):297–8.

36.LyonAR,MunsonSA,RennBN,etal.Useofhuman-centered designtoimproveimplementationofevidence-based psychotherapiesinlow-resourcecommunities:protocolfor studiesapplyingaframeworktoassessusability. JMIRResProtoc. 2019;8(10):e14990.

37.AroraDR,MaheshwariM,AroraB.Rapidpoint-of-caretestingfor detectionofHIVandclinicalmonitoring. ISRNAIDS. 2013;2013:287269.

38.SmooklerD,VanderhoffA,BiondiMJ,etal.Reducingreadtime ofpoint-of-caretestdoesnotaffectdetectionofhepatitisCvirusand reducesneedforreﬂexRNA. ClinGastroenterolHepatol. 2021;19(7):1451–8.e4.

39.WagnerKD,HardingRW,KelleyR,etal.Post-overdoseinterventions triggeredbycalling911:centeringtheperspectivesofpeoplewhouse drugs(PWUDs). PLoSOne. 2019;14(10):e0223823.

40.BergsteinRS,KingK,Melendez-TorresGJ,etal.Refusaltoaccept emergencymedicaltransportfollowingopioidoverdose,andconditions thatmaypromoteconnectionstocare. IntJDrugPolicy. 2021;97:103296.

41.Champagne-LangabeerT,Bakos-BlockC,YatscoA,etal.Emergency medicalservicestargetingopioiduserdisorder:anexplorationofcurrent out-of-hospitalpost-overdoseinterventions. JAmCollEmerg PhysiciansOpen. 2020;1(6):1230–9.

42.MistlerCB,ChandraDK,CopenhaverMM,etal.Engagement inharmreductionstrategiesaftersuspectedfentanylcontamination amongopioid-dependentindividuals. JCommunityHealth. 2021;46(2):349–57.

43.SealKH,DowningM,KralAH,etal.Attitudesaboutprescribing take-homenaloxonetoinjectiondrugusersforthemanagement ofheroinoverdose:asurveyofstreet-recruitedinjectors intheSanFranciscoBayArea. JUrbanHealth. 2003;80(2):291–301.

44.StrangJ,PowisB,BestD,etal.Preventingopiateoverdosefatalities withtake-homenaloxone:pre-launchstudyofpossibleimpactand acceptability. Addiction. 1999;94(2):199–204.

45.McDonaldRandStrangJ.Aretake-homenaloxoneprogrammes effective?SystematicreviewutilizingapplicationoftheBradfordHill criteria. Addiction. 2016;111(7):1177–87.

46.StrangJ,McDonaldR,CampbellG,etal.Take-homenaloxone fortheemergencyinterimmanagementofopioidoverdose:thepublic healthapplicationofanemergencymedicine. Drugs. 2019;79(13):1395–418.

47.JonesJD,CampbellA,MetzVE,etal.Noevidenceofcompensatory druguseriskbehavioramongheroinusersafterreceivingtake-home naloxone. AddictBehav. 2017;71:104–6.

48.LeSaintKT,MontoyJCC,SilvermanEC,etal.Implementationofa leave-behindnaloxoneprograminSanFrancisco:aone-year experience. WestJEmergMed. 2022;23(6):952–7.

49.ScharfBM,SabatDJ,BrothersJM,etal.Bestpracticesforanovel EMS-basednaloxoneleavebehindprogram. PrehospEmergCare. 2021;25(3):418–26.

50.PublicHealth Seattle&KingCounty.Streetmedicineforpeopleliving unsheltered.2021.Availableat: https://kingcounty.gov/depts/health/ locations/homeless-health/mobile-medical-care/street-medicine.aspx AccessedonFebruary23,2023.

51.ChoiBY,BlumbergC,WilliamsK.Mobileintegratedhealthcareand communityparamedicine:anemergingemergencymedicalservices concept. AnnEmergMed. 2016;67(3):361–6.

52.MechemCC,YatesCA,RushMS,etal.Deploymentofalternative responseunitsinahigh-volume,urbanEMSsystem. PrehospEmerg Care. 2020;24(3):378–84.

53.BurtonWandMartinA.Opioidoverdoseandaddictiontreatment: acollaborativemodelofcompassion,patience,andrespect. JNursScholarsh. 2020;52(4):344–51.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

PragmaticEmergencyDepartmentInterventionReducingDefault QuantityofOpioidTabletsPrescribed

DrakeGothamJohnson,MS° AliceY.Lu,MSL°

GeorgiaA.Kirn, °

KaiTrepka,AM°

YeseniaAyanaDay, °

StephenC.Yang,DDS°

JuanCarlosC.Montoy,MD,PhD

MarianneA.Juarez,MD

SectionEditor:R.GentryWilkerson,MD

UniversityofCaliforniaSanFrancisco,DepartmentofEmergencyMedicine, SanFrancisco,California

°Johnson,Lu,Kirn,Trepka,Day,andYangareco-ﬁrstauthors.

Submissionhistory:SubmittedApril1,2023;RevisionreceivedJanuary24,2024;AcceptedFebruary9,2024

ElectronicallypublishedMay20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18040

Introduction: TheopioidepidemicisamajorcauseofmorbidityandmortalityintheUnitedStates.Prior workhasshownthatemergencydepartment(ED)opioidprescribingcanincreasetheincidenceofopioid usedisorderinadose-dependentmanner,andsystemicchangesthatdecreasedefaultquantityof dischargeopioidtabletsintheelectronichealthrecord(EHR)canimpactprescribingpractices.However, EDleadershipmaybeinterestedintheimpactofcommunicationaroundtheinterventionaswellas whethertheinterventionmaydifferentiallyimpactdifferenttypesofclinicians(physicians,physician assistants[PA],andnursepractitioners).Weimplementedandevaluatedaqualityimprovement interventionofanannounceddecreaseinEHRdefaultquantitiesofcommonlyprescribedopioidsata large,academic,urban,tertiary-careED.

Methods: WegatheredEHRdataonallEDdischargeswithopioidprescriptionsfromJanuary1, 2019–December6,2021,includingchiefcomplaint,clinician,andopioidprescriptiondetails.Datawas capturedandanalyzedonamonthlybasisthroughoutthistimeperiod.OnMarch29,2021,we implementedanannounceddecreaseinEHRdefaultdispensequantitiesfrom20tabletsto12tabletsfor commonlyprescribedopioids.Wemeasuredpre-andpost-interventionquantitiesofopioidtablets prescribedperdischargereceivingopioids,distributionbypatientdemographics,andinter-clinician variabilityinprescribingbehavior.

Results: TheEHRchangewasassociatedwitha14%decreaseinquantityofopioidtabletsper dischargereceivingopioids,from14to12tablets(P =<.001).Wefoundnostatisticallysignificant disparitiesinprescriptionsbasedonself-reportedpatientrace(P = 0.68)orgender(P = 0.65).Nurse practitionersandPAsprescribedmoreopioidsperencounterthanphysiciansonaverageandhada statisticallysignificantdecreaseinopioidprescriptionsassociatedwiththeEHRchange.Physicianshad alesserbutstillsignificantdropinopioidprescribinginthepost-interventionperiod.

Conclusion: DecreasingEHRdefaultsisarobust,simpletoolfordecreasingopioidprescriptions,with potentialforimplementationinthe42%ofEDsnationwidethathavedefaultsexceedingtherecommended 12-tabletsupply.Consideringsigniﬁcantinter-clinicianvariability,futureinterventionstodecreaseopioid prescriptionsshouldexaminetheeffectsofcombiningEHRdefaultchangeswithtargetedinterventionsfor cliniciangroupsorindividualclinicians.[WestJEmergMed.2025;26(1.1)18–25.]

INTRODUCTION

Theopioidepidemicisamajorcauseofmorbidityand mortalityintheUnitedStates,includinginCalifornia.1 Opioidprescriptionsinitiatedintheemergencydepartment (ED)andotherclinicalcaresettingscanincreasethe incidenceofopioidusedisorder(OUD)inadose-dependent manner themoretabletsprescribed,thegreatertheriskof futuredevelopmentofOUD.2–4 Inaddition,thepresenceof excessopioidtabletsinthehomeislinkedtodiversionand overdose.5 Decreasingthetotalquantityoftabletsprescribed fromtheEDmayhelpdecreasetheriskoftheseharms.

Manyinterventionsattempttodecreaseandalleviatethe risksofopioidprescriptionsinEDsettings,fromelectronic clinicaldecisionsupportalertstoco-prescriptionofnaloxone, butmostexistingEDinterventionsfocusondecreasing prescriptionratesratherthandecreasingthequantityofopioid tabletsprescribedwhenEDpatientsaredischargedwith opioids.6–8 Priorresearchhasshownthatdecreasingthe defaultquantityoftabletsprescribedintheelectronichealth record(EHR)withoutannouncingthechangetoclinicians candecreasethenumberofopioidsperprescriptiongivenat discharge.Inthesestudies,clinicianswerenotnotiﬁedof alteredEHRdefaultprescriptionseitherforconvenienceorto testtheeffectofadefaultchangealone,orduetoconcernthat clinicianswouldconsciouslyoverridethedefaults.9–13

BecauseprotocolchangesintheEDarecommonly arrivedatbyconsensusandareusuallyimplemented transparentlyratherthanunannounced,studyingtheeffect ofanannouncedEHRchangemorecloselymirrorsrealworldscenarios.Anannouncementaboutthechangemay havetheaddedbeneﬁtofeducatingcliniciansaboutopioid prescribingguidelines,therisksofprescribingopioids,and signalswhatothercliniciansarethinkingaboutopioid prescriptions.Further,thereisevidencethatnurse practitioners(NP)andphysicianassistants(PA)aremore likelythanphysicianstoprescribeopioidsinprimarycare settings,14 buttherelationshipbetweencliniciantypeand opioid-prescribingbehaviorintheEDsettingremains unknown.Inaddition,priorworkhasnotshownwhether thesedifferenttypesofcliniciansrespondsimilarlytodefaultdirectedattemptstodecreaseopioidprescribing.

Toaddressthesegaps,weimplementedaquality improvement(QI)interventiondecreasingEHRdefault quantitiesofcommonlyprescribedopioidsatalarge, academic,urban,tertiary-carecenter.Ourgoalwasto determinewhetherthisEHRchangewasassociatedwith decreasedopioidprescribingandwhetherthisassociation variedbycliniciantype.

METHODS

Design

Weimplementedasingle-site,QIinterventionatalarge, academic,urbantertiary-careEDalteringthedefaultquantity ofsixcommonlyprescribedopioids.ThiswasaprospectiveQI

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartment opioidprescriptions increasetheincidenceofopioidusedisorderin adose-dependentmanner,potentially exacerbatingtheopioidepidemic.

Whatwastheresearchquestion?

Thisstudyevaluatedtheimpactofa qualityimprovementinterventiondecreasing defaultopioidquantitiesintheEHRfrom 20pillsto12,onaverageopioidsprescribed atdischarge.

Whatwasthemajor ﬁnding ofthestudy?

TheEHRchangewasassociatedwitha14% decreaseinquantityofopioidtabletsper dischargereceivingopioids(P < .001),driven mostlybynursepractitioners ’ andphysician assistants ’ changes.

Howdoesthisimprovepopulationhealth?

Wedemonstrateasimpleinterventionother emergencydepartmentscanimmediately implementtoreducetheburdenopioid prescribinghasontheopioidepidemic.

studywheredatawaspulledfromchartreviewandanalyzed bothduringstudydesignandcontinuouslyduring implementation.Wecollectedpre-interventiondataonallED dischargesreceivingthesesixopioidsatdischargefrom January1,2019–March28,2021,andcomparedthiswith post-interventiondatafromMarch29,2021–December5, 2021.ThisworkwasconsideredQIactivityaccordingtothe UniversityofCalifornia,SanFranciscoinstitutionalreview boardpolicy.Asaresult,therequirementforindividual researchHIPAAauthorizationandsignedconsentformswas waivedforallsubjectsastheresearchpresentednomorethan minimalriskofharmtothesubjects’ privacy.

Intervention

Wedecreasedthepre-populatedEDdischargedispense quantitiesintheEHRfrom20tabletsto12tabletsforthe followingsixcommonlyprescribedopioids:oxycodone 5milligrams(mg);oxycodone-acetaminophen5–325mg; oxycodone10mg;tramadol50mg;hydrocodoneacetaminophen5–325mg;andhydrocodone-acetaminophen 10–325mg.Changesweremadeatthesystemleveland appliedtoallEDpatientsandclinicians.Cliniciansdecided

forwhomtoprescribeopioidsandcouldchooseanyquantity byalteringthedefaultsetting.CliniciansintheEDwere informedofthestudyandquantitychangesusingtwo communicationmethods:bytwoemailannouncementssent toallphysicians,PAs,andNPs;andbytwoin-person announcementsduringtheweeklyall-staffEDmeetings attendedby10–12totalphysicians,PAs,andNPs.Theemail andweeklyall-staffannouncementsweremadeoveraperiod oftwoweekspriortotheintervention.

Participants

WeincludedEDpatientencountersinwhichpatientswere dischargedfromtheEDwithaprescriptionforoneofthesix opioidmedicationsincludedintheintervention.Wealso recordedthetotalnumberofpatientsdischargedfromthe EDeachmonthduringtheperiodofourstudy,regardlessof whethertheyweregivenaprescriptionattheendoftheir visit.Eachencounterwasrecordedasanobservation, regardlessofwhetherthesepatientshadotherEDvisits.

Outcomes

FromallEDencountersthathadanopioidmedication prescribedatdischarge,weextractedthefollowingdatafrom theEHR:dateofvisit;patientdemographics(race,age, gender,insurancetype);acuity(basedontheassigned EmergencySeverityIndexscoreintheEHR),chief complaint,prescribingcliniciantype,opioidmedication prescribedandquantityoftablets.Insurancetypewas categorizedasMedicaid,Medicare,commercial,self-pay,or other.Chiefcomplaintswereclassiﬁedintothefourmost commonchiefcomplaintsseeninourEDoverthestudy period(backpain,abdominalpain, ﬂankpain,falls),withthe remainingchiefcomplaintsgroupedas “other.” Prescribing cliniciantypeswerecategorizedasphysician,NP,orPA.

Ourprimaryoutcomemeasurewasthedifferenceinmean numberofopioidtabletsprescribedatdischargebeforeand afterourintervention.Oursecondaryoutcomesincluded differencesinthismeasuregiventhepatient’sself-reported raceandself-reportedgender,aswellasprescribingclinician typefortheencounter(physician,NP,PA).Wealsotested thedifferenceinmeanmorphinemilligramequivalents (MME)prescribedatdischargebeforeandafter ourintervention.

Analysis

WecalculatedMMEsusingtheconversionfactors providedbytheUSCentersforDiseaseControland Prevention(CDC).4 Frequencytablesweregeneratedfor categoricalvariables.Medianandinterquartilerangewere generatedforageandmeans,andstandarddeviationswere calculatedforallothercontinuousvariables.Weperformed twosample t -teststocomparemeanopioidtabletsprescribed beforeandafterourinterventionandcalculated95% conﬁdenceintervals(CI).GiventheeffectoftheCOVID-19

pandemiconthevolumeofEDdischargesduringourpreinterventiondatacollection,weperformedsensitivity analysesrestrictingthestudyperiodtodifferentstarttimes, includingafterthestartoftheCOVID-19pandemic(in March2020).Weperformedchi-squaretestsof independenceforage,race,insurancetype,andacuitybefore andafterintervention,andtheFisherexacttestforgender. Two-wayanalysisofvariance(ANOVA)wasperformedto analyzetheinteractionbetweencliniciantypeand interventiononmeanopioidtabletsprescribed. P values < 0.05werereportedassigniﬁcant.Weperformedallanalyses usingPython3(PythonSoftwareFoundation, Wilmington,DE).

RESULTS

Therewere3,575EDdischargeswithanopioidprescribed duringthestudyperiod,ofwhich3,274(91.6%)had prescriptionsforoneofthesixopioidstargetedbyour intervention,including2,666dischargespre-interventionand 608dischargespost-intervention. Opioidsnottargeted byour interventionincludedmorphine(2.5%),hydromorphone (1.4%), oxycodone (1.3%),hydrocodone(<1%),codeine (<1%), tramadol (<1%),methadone(<1%),andfentanyl (<1%).ThepatientpopulationseenintheEDpre-andpostinterventionhadsimilardistributionsofdischargediagnoses, age,gender,self-reportedrace,acuity,insurancetype,and prescribingcliniciantype(Table1).Therewereno statisticallysigniﬁcantdifferencesinprescriptionsbetween individualswithdifferentself-reportedraces(chi-squared P = 0.68)orbetweengenders(Fisherexact P = 0.65)before andafterimplementationofourintervention.

ThenumberofEDencountersassociatedwithanopioid prescriptionupondischargewasproportionaltothetotal numberofdischargesfromtheEDthroughoutthestudy period,althoughbothexperiencedaprecipitousdeclineat thestartoftheCOVID-19pandemic(Figure1).

DecreasingtheEHRdefaultquantityofcommonly prescribedopioidswasassociatedwithadecreasefrom14.01 to12.00tabletsperdischargeprescriptionwithopioidsfrom theED,adifferenceof2.01tablets(95%CI1.44–2.58) (Table2).Sensitivityanalysisshowedtherewasastatistically signiﬁcantdifferenceintabletsprescribedregardlessofhow manymonthswereincludedinthepre-interventiondataset (SupplementalTable1).Thisdecreaseintabletsismirrored byan11.0MMEdecreaseperdischargeprescriptionwith opioids(95%CI5.74–16.22)from94.25to83.27(Table2).

For2,666pre-interventionencountersinthedataset, physicianswrote47.6%ofstudyprescriptions,NPswrote 26.8%,andPAswrote25.6%ofstudyprescriptions.Forthe 608post-interventionencountersinthedataset,physicians wrote50%ofstudyprescriptions,NPswrote24.3%,andPAs wrote25.7%ofstudyprescriptions.Allcliniciantypes prescribedsigniﬁcantlyfeweropioidsperencounterafterthe interventioncomparedtoprior,withPAsandNPsaffected

Table1. Patientdemographicsofopioidprescriptionsintheemergencydepartment.

PatientdemographicsAllPrePost

Age,median(IQR)48(27)48(27)48(29)0.88

Gender,n(%)

Female1,707(0.522)1,395(0.5242)312(0.514)

Male1,561(0.478)1,266(0.4758)295(0.486)

Race,n(%)

White1,719(0.525)1,393(0.5225)326(0.536)

Black423(0.129)353(0.1324)70(0.115)

Asian467(0.143)382(0.1433)85(0.14)

Other665(0.203)538(0.2018)127(0.209)

Acuity,n(%)

Emergent286(0.087)243(0.0912)43(0.071)

Urgent2,013(0.615)1,618(0.6071)395(0.65)

Lessurgent947(0.289)781(0.2931)166(0.273)

Non-urgent27(0.008)23(0.0086)4(0.007)

Commercial1,448(0.442)1,172(0.4396)276(0.454)

Medicaid801(0.245)662(0.2483)139(0.229)

Medicare702(0.214)571(0.2142)131(0.216)

Self-pay167(0.051)140(0.0525)35(0.058)

Other156(0.048)121(0.0454)27(0.044)

Physician1,573(0.481)1,269(0.476)304(0.5)

NP862(0.263)714(0.268)148(0.243)

PA839(0.256)683(0.256)156(0.257)

Dischargediagnosis,n(%)

Abdominalpain425(0.130)345(0.129)80(0.131)

Backpain324(0.0990)258(0.0968)66(0.109)

Flankpain292(0.0892)248(0.0930)44(0.0724)

Fall190(0.0580)41(0.0559)149(0.0674)

Other2,043(0.624)1,666(0.624)377(0.620)

IQR,interquartilerange; NP,nursepractitioner; PA,physicianassistant.

themost(Figure2, Table3).Atwo-wayANOVAofthe cliniciantypeandinterventionconﬁrmedstatistically signiﬁcanteffectsoftheintervention,cliniciantype,and interactionbetweeninterventionandcliniciantypeonthe numberoftabletsperdischargeprescriptionwith opioids(P < 0.001).

DISCUSSION

WeimplementedanannounceddecreaseinEHRdefault quantitiesofsixcommonlyprescribedopioidsatalarge, academic,urban,tertiary-careED.Theanalysisofour primaryoutcomeshowedthatthisQIinterventionwas associatedwithastatisticallysigniﬁcantdecreaseinopioid

tabletsperdischargeprescriptionwithopioidsfromtheED, from14to12tablets,andacorresponding11-pointdecrease inmeanMMEsprescribed.Whilenostudieshaveprecisely quantifiedtheclinicalsignificanceofthislevelofdecrease, priorliteratureandCDCguidelinesnoteadose-dependent relationshipbetweenprescriptionsandriskofdeveloping OUD,suggestingthateverypillmattersatapopulation level.2–4 Further,giventhatthiscenter’spre-intervention meantabletsperEDdischargeopioidprescriptionwasonly 14,themaximumexpecteddecreasefromadefaultchangeto 12wasonlyadecreaseoftwotabletsperdischarge prescription.However,theseinterventionsmightconfera largerclinicalsignificanceatotherinstitutionswithahigher

Figure1. DecreasingdefaultopioidquantitiesintheelectronichealthrecordisassociatedwithlowerEDprescriptionofopioidsinthe emergencydepartment.Numberoftotaldischarges(blue)anddischargesinwhichopioidswereprescribed(orange)overthestudytimeline. TheinterventionbeganonMarch19,2021.

Table2. Tabletsandmorphinemilligramequivalentsperdischargeprescriptionwithopioids.

Opioidprescriptions

CI,conﬁdenceinterval; MME,morphinemilligramequivalent.

Figure2. Cliniciantypeisassociatedwithopioidprescriptionquantitiesintheemergencydepartment.Averagenumberoftablets perdischargeinwhichopioidswereprescribed,groupedbycliniciantypeandinterventiontime(blue = pre-intervention, orange = post-intervention).

Table3. Numberoftabletsperdischargeprescriptionwithopioids,bycliniciantype.

NP,nursepractitioner; PA,physicianassistant; CI,conﬁdenceinterval.

startingmeantabletsperdischarge.Importantly,we observedthatNPsandPAsintheEDsettingaremorelikely thanphysicianstoprescribehigherlevelsofopioidsat baseline,consistentwithpreviousresultsinprimary caresettings.14

Ourresultssuggestthatauniversaldefaultchangeis associatedwithdecreasedopioidprescriptionsacrossall clinicians,withlargerdecreasesforNPsandPAscompared tothechangeobservedforphysicians.Thehigherratesof opioidprescriptionsamongNPsandPAscouldbeduetoa varietyoffactors,includingdifferencesintheacuityortypes ofillnessesandinjuriesevaluated.Additionally,evenafter theintervention,thehighaverageopioidsprescribedinthe NPgroupwasdrivenbyafewcliniciansstillfarexceedingthe default(SupplementalFigure1).Theexistenceofinterclinicianvariabilityinprescriptionsmayprovide opportunitiesformoretargetedfutureinterventions,suchas NP-orPA-speciﬁcinterventionsinconjunctionwithEHRdriveninterventions.

Wechosetoanalyzetheaveragenumberoftablets prescribedperencounterinwhichopioidswereprescribed ratherthanperEDvisitorpermonth.Averagenumberof tabletsalignsmoredirectlywithourintervention,whichwas aimedatreducingthequantityofopioidsprescribedaftera clinicianhadalreadydeterminedaneedforopioidanalgesia. Additionally,thenumberoftabletsprescribedperopioid encounterislessimpactedbytemporalandseasonal variationinprescribingpatternsandvisitacuity,including theeffectoftheCOVID-19pandemic.

Inmostpriorstudies,clinicianswerenotnotiﬁedofaltered EHRdefaultprescriptionseitherforconvenienceortotest theeffectofadefaultchangealone,orduetoconcernthat clinicianswouldconsciouslyoverridethedefaults.9–13 However,wefoundthatdecreasingdefaultEHRopioid quantitiesto12tabletscoupledwithinformingcliniciansof theEHRchangeresultedinadecreaseinthetotalnumberof opioidsprescribedatEDdischarge.Weobserveddecreases intheaveragenumberoftabletsprescribedperpatientand theaverageMMEoftabletsprescribedperpatient.This suggeststhattransparencywithcliniciansregardingbest practicesinopioidprescribingdoesnotnegatetheeffectof alteringEHRdefaults.Itispossiblethatanannouncementto cliniciansabouttheEHRchangeandtherationalebehindit mayserveasaneducationalfeedbackcomponenttothe

intervention.Clinicianswhoappreciatethepurposeofthe defaultchangemaybemorelikelytousethedefault,golower thanthedefault,orevenwritefewerprescriptionsastheysee ﬁtforeachclinicalscenario,consistentwithpriorwork demonstratingthatauditandfeedbackapproachescan decreaseopioidprescribing.15

Becausepriorworkhasdemonstratedtheexistenceof racialdisparitiesinopioidprescribing,weinvestigated whetherclinicians’ opioidprescribingbehaviordiffered basedonpatientdemographics.16 Ouranalysisshowedthat therewasnostatisticallysigniﬁcantdisparityinopioid prescriptionamountsbasedonpatientdemographics, includingage,race,andgender,forboththepre-andpostinterventiondata.

ItisalsoimportanttonotethattheCOVID-19pandemic startedduringourpre-interventionphase,whichresultedin anoveralldecreaseinEDutilization.17 However,our outcomeissomewhatinsulatedfromchangesinEDvolume, astabletsperprescriptionshouldnotbedependentonthe numberofpatientdischarges.TheCOVID-19pandemicmay haveledtoothermoresubtlechangesinprescribingbehavior secondarytochangingpatientpopulationsseen,butthe majorchiefcomplaintsdidnotdifferinthepre-and post-interventionperiod,andtheresultsofoursensitivity analysisconﬁrmedthattheeffectseenwasstillpresent evenafterrestrictingourdatatoanentirely post-COVID-19timeframe.

Ultimately,werecognizethatopioidsremain ﬁ rst-line treatmentsforcertainindicationssuchasshort-termpain reliefforacutefracturesandcancerpainandareoften necessaryatdischargefromtheED.However,giventhe risksofdiversion,overdose,andOUDassociatedwith dischargingpatientswithlargequantitiesofopioidtablets, itisimportanttoencourageemergencycliniciansto dischargepatientswithaclinicallyappropriateyetsafe quantityoftablets.Itisalsoimportanttousediscretionas opioidsareoftennotindicatedforcertainothercausesof paininpatientspresentingtotheED,includingthe commonchiefcomplaintsofabdominalpainandlower backpain.18 Recommendationsforacutepainsuggest dischargingpatientswithathree-daysupplyofopioid medications,whichcorrespondsto12tabletsorless.19 Our approachisapragmatic,transparent,andscalable interventionthatoffersatoolthatcanbeimplementedin

the42%ofEDsnationwidethatcurrentlyhavedefaults exceeding12tablets.19

LIMITATIONS

Ourstudydesignofasingle-site,pre/poststudydoesnot allowforacausalinterpretationandlimitsgeneralizability. MuchoftheprojectoccurredduringtheCOVID-19 pandemic,inwhichopioidprescribingincreasednationwide; however,patternsforEDdischargeprescriptionshavenot beenstudied.20 Ourdesigndidnotallowustomeasure associatedharmsorbeneﬁts,suchaswhetherpaincontrol wasadequateorwhetherdiversiondecreased.21 Neitherdid ourdesignallowustotestfordifferencesinwhetherpatients wereprescribedopioids,whichisalsoanimportant considerationforopioidstewardship.Additionally,the 12-tabletdefaultquantitywaschosentoapproximatea three-daysupply,butthislengthmayvarybasedonthe frequencyprescribedofagivenopioid,andthereislimited evidencetosupporttheoptimaltimecourseofopioids atdischarge.22

Finally,thestudydesigndidnotallowustomeasurethe precisenumberofclinicianswhowereexposedtothe clinician-facingannouncement,differentiatewhetherthe effectsobservedwereattributabletotheEHRchangesalone, theclinician-facingannouncementalone,oracombination ofthetwo.

CONCLUSION

Wedemonstratedthataqualityimprovement interventioncouplingdecreaseddefaultopioidquantitiesin theelectronichealthrecordwithinformingcliniciansofthe EHRchangewasassociatedwithadecreaseinthetotal numberofopioidsprescribedfromtheED.Whileall cliniciantypes(NPs,PAs,andphysicians)decreasedtheir quantitiesofopioidsprescribedperdischargefollowingthe defaultchange,NPsandPAsprescribedmoreopioidsthan physiciansinitiallyandexperiencedalargerdecreasein opioidprescriptions.Futureinterventionsseekingtoaddress EDopioidprescribingshouldmeasurethetotalquantityof opioidsleavingtheEDoverlongerperiodsoftime,usea robust,patient-centeredmetricforpainmanagementfollowup,andattempttocorrelateEDopioidprescriptionswith negativeopioid-associatedoutcomesinbothindividual patientsandtheircommunities.

AddressforCorrespondence:MarianneJuarez,MD,Universityof CaliforniaSanFrancisco,DepartmentofEmergencyMedicine,521 ParnassusAvenue,7th ﬂoor,SanFrancisco,CA94143.Email: Marianne.Juarez@ucsf.edu

ConﬂictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallafﬁliations,fundingsources

and ﬁnancialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.KaiTrepkawassupportedbygrant T32GM007618fromtheNationalInstituteofGeneralMedical SciencesoftheNationalInstitutesofHealth.Therearenoother conﬂictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.SchieberLZ,GuyGP,SethP,etal.Trendsandpatternsofgeographic variationinopioidprescribingpracticesbystate,UnitedStates, 2006–2017. JAMANetwOpen.2019;2(3):e190665.

2.ShahA,HayesCJ,MartinBC.Characteristicsofinitialprescription episodesandlikelihoodoflong-termopioiduse UnitedStates, 2006–2015. MMWRMorbMortalWklyRep.2017;66(10):265–9.

3.HoppeJ,KimH,HeardK.Associationofemergencydepartment opioidinitiationwithrecurrentopioiduse. AnnEmergMed 2015;65(5):493–9.

4.JohnsonDG,HoVT,HahJM,etal.Prescriptionquantityandduration predictprogressionfromacutetochronicopioiduseinopioid-naïve Medicaidpatients.MattieH,ed. PLOSDigitHealth 2022;1(8):e0000075.

5.Kennedy-HendricksA,GielenA,McDonaldE,etal.Medicationsharing, storage,anddisposalpracticesforopioidmedicationsamongUSadults. JAMAInternMed.2016;176(7):1027.

6.DaoustR,PaquetJ,MarquisM,etal.Evaluationofinterventionsto reduceopioidprescribingforpatientsdischargedfromtheemergency department:asystematicreviewandmeta-analysis. JAMANetwOpen 2022;5(1):e2143425.

7.RathlevN,AlmomenR,DeutschA,etal.Randomizedcontrolledtrialof electroniccareplanalertsandresourceutilizationbyhighfrequency emergencydepartmentuserswithopioidusedisorder. WestJEmerg Med.2016;17(1):28–34.

8.DowellD,HaegerichTM,ChouR.CDCguidelineforprescribingopioids forchronicpain UnitedStates,2016. JAMA.2016;315(15):1624.

9.MontoyJCC,CoralicZ,HerringAA,etal.Associationofdefault electronicmedicalrecordsettingswithhealthcareprofessionalpatterns ofopioidprescribinginemergencydepartments:arandomizedquality improvementstudy. JAMAInternMed.2020;180(4):487.

10.CarlsonA,NelsonME,PatelH.Longitudinalimpactofapre-populated defaultquantityonemergencydepartmentopioidprescriptions. JAm CollEmergPhysiciansOpen.2021;2(1):e12337.

11.ZivinK,WhiteJO,ChaoS,etal.Implementingelectronichealthrecord defaultsettingstoreduceopioidoverprescribing:apilotstudy. Pain Med.2019;20(1):103–12.

12.DelgadoMK,ShoferFS,PatelMS,etal.Associationbetweenelectronic medicalrecordimplementationofdefaultopioidprescriptionquantities andprescribingbehaviorintwoemergencydepartments. JGenIntern Med.2018;33(4):409–11.

13.SantistevanJ,SharpB,HamedaniA,etal.Bydefault:theeffectof prepopulatedprescriptionquantitiesonopioidprescribinginthe emergencydepartment. WestJEmergMed.2018;19(2):392–7.

14.LozadaMJ,RajiMA,GoodwinJS,etal.Opioidprescribingbyprimary careproviders:across-sectionalanalysisofnursepractitioner, physicianassistant,andphysicianprescribingpatterns. JGenIntern Med.2020;35(9):2584–92.

15.AndereckJW,ReuterQR,AllenKC,etal.Aqualityimprovement initiativefeaturingpeer-comparisonprescribingfeedbackreduces emergencydepartmentopioidprescribing. JtCommJQualPatientSaf 2019;45(10):669–79.

16.KeisterLA,StecherC,AronsonB,etal.Providerbiasinprescribing opioidanalgesics:astudyofelectronicmedicalrecordsatahospital emergencydepartment. BMCPublicHealth.2021;21(1):1518.

17.VenkateshAK,JankeAT,Shu-XiaL,etal.Emergencydepartment utilizationforemergencyconditionsduringCOVID-19. AnnEmergMed 2021;78(1):84–91.

18.KamperSJ,LoganG,CopseyB,etal.Whatisusualcareforlowback pain?Asystematicreviewofhealthcareprovidedtopatientswithlow backpaininfamilypracticeandemergencydepartments. Pain 2020;161(4):694–702.

19.BlutingerEJ,ShoferFS,MeiselZ,etal.Variabilityinemergency departmentelectronicmedicalrecorddefaultopioidquantities:A nationalsurvey. AmJEmergMed.2019;37(10):1963–4.

20.LeeB,YangKC,KaminskiP,etal.Substitutionofnonpharmacologic therapywithopioidprescribingforpainduringtheCOVID-19pandemic. JAMANetwOpen.2021;4(12):e2138453.

21.DuncanRW,SmithKL,MaguireM,etal.Alternativestoopioids forpainmanagementintheemergencydepartmentdecreases opioidusageandmaintainspatientsatisfaction. AmJEmergMed 2019;37(1):38–44.

22.McCarthyDM,KimHS,HurSI,etal.Patient-reportedopioidpill consumptionafteranEDvisit:Howmanypillsarepeopleusing? Pain Med.2021;22(2):292–302.

REVIEW:SUBSTANCE USE DISORDER

BystandersSavingLiveswithNaloxone:AScopingReviewon MethodstoEstimateOverdoseReversals

AndrewT.Kinoshita,MPH* SoheilSaadat,MD,PhD,MPH† BharathChakravarthy,MD,MPH†

SectionEditor:R.GentryWilkerson,MD

*UniversityofCaliforniaIrvine,SchoolofMedicine,Irvine,California † UniversityofCaliforniaIrvine,SchoolofMedicine,DepartmentofEmergency Medicine,Irvine,California

Submissionhistory:SubmittedApril1,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary12,2024

ElectronicallypublishedMay21,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18037

Introduction: Peoplewhousedrugsincommunitysettingsareatriskofafataloverdose,whichcanbe mitigatedbynaloxoneadministeredviabystanders.Inthisstudywesoughttoinvestigatemethodsof estimatingandtrackingopioidoverdosereversalsbycommunitymemberswithtake-homenaloxone (THN)tocoalescepossiblewaysofcharacterizingTHNreachwithametricthatisusefulforguidingboth distributionofnaloxoneandadvocacyofitsbeneﬁts.

Methods: WeconductedascopingreviewofpublishedliteratureonPubMedonAugust15,2022,using PRISMA-ScRprotocol,forarticlesdiscussingmethodstoestimateTHNreversalsinthecommunity.The followingsearchtermswereused: naloxoneAND(“takehome” ORkitOR “communitydistribution” OR “naloxonedistribution”).Weusedbackwardscitationsearchingtopotentially ﬁndadditionalstudies. Overdoseeducationandnaloxonedistributionprogram-basedstudiesthatanalyzedonlysingle programswereexcluded.

Results: Thedatabasesearchcaptured614studies,ofwhich14studieswererelevant.Backwards citationsearchingof765referencesdidnotrevealadditionalrelevantstudies.Ofthe14relevantstudies, 11weremathematicalmodels.TenusedMarkovmodels,andoneusedasystemdynamicsmodel.Of theremainingthreearticles,onewasameta-analysis,andtwousedspatialanalysis.Studiesrangedin yearofpublicationfrom2013–2022withmathematicalmodelingincreasinginuseovertime.Onlyspatial analysiswasusedwithafocusoncharacterizinglocalnaloxoneuseatthelevelofaspeciﬁccity.

Conclusion: OfexistingmethodstoestimatebystanderadministrationofTHN,mathematicalmodels aremostcommon,particularlyMarkovmodels.Systemdynamicsmodeling,meta-analysis,andspatial analysishavealsobeenused.Allmethodsareheavilydependentuponoverdoseeducationand naloxonedistributionprogramdatapublishedintheliteratureoravailableasongoingsurveillancedata. Overall,thereisapaucityofliteraturedescribingmethodsofestimationandevenfewerwithmethods appliedtoalocalfocusthatwouldallowformoretargeteddistributionofnaloxone.[WestJEmergMed. 2025;26(1.1)26–32.]

INTRODUCTION

Peoplewhousedrugsincommunitysettingshavetherisk ofafataloverdose,whichcanbemitigatedbynaloxone administeredviabystandersduringoverdoseincidents. Currently,thereissomepublichealthinfrastructureinplace totracknaloxonedistribution.InCalifornia,the DepartmentofHealthCareServices(DHCS)actsasahub

fordisseminationofnaloxonetocommunity-based organizations.1 Theseorganizationsare,inturn,charged withmaintainingdistributionandusedata.However,the DHCSisnottheonlydistributorofnaloxone,nordo programsthatdistributenaloxonehaveanywaytorequire individualstoreportuse.Further,naloxoneinNarcannasal sprayformhasrecentlybeenapproved(inMarch2023)by

theUSFoodandDrugAdministrationforover-the-counter (OTC)distribution.Duetothismultitudeoffactors,itisnot knownhowfrequentlycommunity-distributednaloxoneis administeredtotreatoverdose.

Whilenaloxonedistributionisaneffective,evidencebasedintervention,andOTCformulationsareapproved, thereisstillpushbackagainsthighlyvisibleandavailable naloxonedistributionpointsfrompolicymakersand communitymembersduetothestigmaassociatedwithdrug useand,byextension,thelegallandscape.2,3 Inthisstudywe soughttoinvestigatemethodsofestimatingandtracking opioidoverdosereversalsbycommunitymemberswithtakehomenaloxone(THN)tocoalescepossiblewaysof characterizingTHNreachwithametricthatisusefulfor guidingbothdistributionofnaloxoneandadvocacy ofitsbeneﬁts.

METHODS

WithPRISMA-ScRprotocolusingthePubMed database,4 weconductedascopingreviewonmethodsto estimateopioidoverdosereversalsbycommunitymembers usingTHN,beforeanypotentialinterventionby ﬁrst respondersorclinicians.Thedatabasesearchwasfollowed bybackwardscitationsearchingtoidentifyrelevantarticles omittedinthedatabasesearch.PubMed,adatabase providedbytheNationalCenterforBiotechnology InformationattheUSNationalLibraryofMedicine,was usedforthescopingreviewduetoitscoverageof 35millioncitationscontainedwithintheliterature compilationsofMEDLINE,PubMedCentral, andBookshelf.5

SearchStrategy

WeperformedasearchonAugust15,2022,using PubMedto ﬁndarticlesthatdiscussedsurveillanceor estimationofTHNadministration.Thesearchwasrestricted toarticlespublishedintheEnglishlanguage,butitwasnot restrictedbyyearofpublication.Thetermsusedforthe searchstrategywereselectedtoensurethatrelevantstudies foundinpilotsearcheswereallincluded.Sincetherehasbeen anevolvinglexiconsurrounding “take-home” naloxone, alternativetermshadtobeincludedinthesearch,even thoughthisdilutedtheproportionofrelevantstudiesinthe ﬁnalsearch.Weusedthefollowingsearchterms: naloxone AND( “ takehome ” ORkitOR “ communitydistribution ” OR “ naloxonedistribution ” ) . ArticlesfromthePubMedsearchthatdiscussedTHNand werepossiblyrelatedtosurveillanceorestimationwere sortedintomethodologybucketsforpossiblefurtherreview basedontitleandabstract,orreviewoffullarticleswhere uncertaintyexisted.Thesemethodologybucketsincludedthe following:1)mathematicalmodels;2)meta-analysis; 3)spatialanalysis;4)otherpossiblyrelevantarticles; 5)opioidoverdoseeducationandnaloxonedistribution

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Administrationofnaloxonemitigatestherisk ofafataloverdoseincommunitysettings; however,surveillanceofcommunitynaloxone anditsadministrationisweak.

Whatwastheresearchquestion?

Whatmethodsexistfortrackingorestimating opioidoverdosereversalsbycommunity memberswithnaloxone?

Whatwasthemajor ﬁndingofthestudy?

Thescopingreviewyielded14studies:11 mathematicalmodels,onemeta-analysis,and twospatialanalyses.

Howdoesthisimprovepopulationhealth?

Fewmethodshavebeenpublishedtoestimate communitynaloxoneadministration; methodsmustbeadaptedforlocalusebefore informingpolicyoradvocacy.

(OEND)program-basedstudies;and6)otherarticles deemednotrelevant.

Thearticlessortedintothe firstfourbuckets mathematicalmodels;meta-analysis;spatialanalysis;and otherpossiblyrelevantarticles werereadinfullfor confirmationof finalinclusion.Weexcludedfromfurther reviewbucket5(OENDprogram-basedstudies)because thesestudieshavestraightforwardmethodologyandare alreadyawell-knownmethodoftrackingTHN administration,whichisevidencedbythenumberofOEND program-basedstudies(59studiescapturedwithour databasesearchstrategy).TheseOENDprogram-based studiesarediscussedfurtherinthe Discussion section.After selectionofPubMedarticlesfor finalinclusion,we performedbackwardscitationsearchingonthesearticles usingtitles,withabstractsasneeded.Thefulltextofpossibly relevantarticleswasreviewedfor finalinclusion.

DataExtractionandSynthesis

Weextractedthefollowingdatausingastandardized table:method(bucket);modeltype;datasources;location (country,location – community);andfundingsources. Methodcorrespondedtothebucketcategoriesdiscussed above.Modeltypewasrelevantforstudiesinbucket1 (mathematicalmodels),andtherecordedmodeltypewas basedonhowauthorsself-describedtheirstudies.Theseself-

descriptionsformathematicalmodelsincludedMarkov modelingandsystemdynamicsmodeling.Datawas synthesizedthroughconceptmapping.

RESULTS

Thedatabasesearchresultedinthecaptureof614studies. Ofthese,108studiesweremarkedaspossiblyrelevantbased ontitlesorabstractsdiscussingTHNprograms,surveillance, orestimation.Usingfullarticlesasneeded,39studieswere categorizedintobucketsofinterest(1–4).Following categorization,fullarticlereviewresultedin14articlesfor finalinclusion.Backwardscitationsearchingofthe765 referencescontainedwithinthe14articlesresultedinthree articlesforfullreview.Allthreewereexcludedfrom final analysisleaving14articlesfor finalinclusion.These14 articleswerefrombuckets1–3. Figure1 presentsa flowchart ofthecapturesandthereviewofliterature.

StudyCharacteristics

Theincludedstudiesvariedintheirobjectives.Developing awaytoidentifyhowmuchnaloxonewasadministeredby bystanderswasoftenacontributortotheoverallgoalsofthe studiesinsteadoftheprimaryobjective.Thissectionpresents asynthesisofstudyobjectivesandthemethodsemployedto surveilorestimatecommunitynaloxoneuse.The Table presentsanoverviewofthestudiesbymethod.

MathematicalModels

Ofthe14studies,11employedmathematicalmodels.Of these,10usedMarkovmodelsandwerepublishedbetween 2012–2022.Markovmodelsdeﬁneseveralnon-overlapping statuses(ie,chronicopioiduse,cessationofopioiduse, overdosing,dead)andrepresenteachindividualwithina simulatedpopulationasamemberofoneofthestatuses.6

Studies identified through database searching. (n = 614)

Abstracts screened. (n = 614)

Abstracts possibly relevant. Categorized into buckets using full text as needed. (n = 108)

Studiescategorized into relevant buckets. Full text reviewed. (n = 39)

Studies included in qualitative synthesis. (n = 14)

Individualstransitionfromonestatetoanother,not necessarilylinearly,basedonprobabilityparametersthat representchangeinindividualstatusesovertime.Thismeans thatmodeloutputofanypriororsubsequentpopulation distributionwithinthesystemcanbederivedfromanygiven populationdistribution.Theoneremainingmathematical modelingstudyusedasystemdynamicsmodelandwas publishedin2022.Systemdynamicsmodelingrepresents differentvariables(ie,population,treatmentavailability, overdosedeaths)withinasystemandtherelationships betweenthem,factoringintemporaldelayasappropriate.7 Thismeansthatthemodeloutputofanysubsequent populationdistributionwithinthesystemmaybebasedon boththegivenpopulationdistributionandthechanges precedingthegivenpopulationdistribution.

Studiesemployingmathematicalmodelsvariedintheir primaryobjectives.FiveofthestudiesemployingMarkov modelsweredesignedtoevaluatethecosteffectivenessof naloxonedistribution.Fourofthesecost-effectiveness studiesusevariationsofthesameMarkovmodel,whichwas originallydevelopedin2013byCofﬁnandSullivan,who authoredtwoofthefourarticles.8–11 Theoneremainingcosteffectivenessstudy,byUyeietal,wasuniqueinthatitalso investigatednaloxonedistributioninconjunctionwithother interventions,includingpre-exposureprophylaxisfor HIVprevention.12

Oftheremaining fiveMarkovmodelstudies,allmodeled theeffectsofnaloxonedistributiononopioidoverdosedeath rates.Coffinetal(2022)modeledtheUSpopulationusing theMarkovmodeldevelopedpreviouslybyCoffinand Sullivanin2013.13 Irvineetal(2018)andIrvineetal(2019) modeledthepopulationofBritishColumbiausingamodel developedbyIrvineetalin2018.14,15 Irvineetal(2022) modeledtheUSpopulation,andLinasetal(2021)modeled

Titles screened from backwards citation searching using abstracts as needed. (n = 765)

Studies excluded;abstracts not relevant. (n = 506)

Study excluded; bucket not relevant. (n = 69)

Studies excluded; full text not relevant. (n = 25)

Abstract relevant and not duplicate study. Full text reviewed. (n = 3)

Studies included in qualitative synthesis. (n = 0)

Studies excluded; title/abstract not relevant or duplicate study. (n = 762)

Studies excluded; full text not relevant. (n = 3)

TOTAL studies included in qualitative synthesis. (n = 14)

Figure1. PRISMA ﬂowchart.

Table. Studycharacteristicsbymethod.

Method (bucket)

Model type First

Mathematical models Markov model

authorYearDatasources

AcharyaM2020Literature, Surveillancedata, Assumption

CofﬁnPO2022Literature, Assumption

CofﬁnPO2013Literature, Expertinput, Assumption

CofﬁnPO2013Literature, Assumption

IrvineMA2018Surveillancedata, Literature, Expertinput, Assumption

IrvineMA2019Surveillancedata, Literature, Expertinput, Assumption

Location country Location communityFundingsources

USUSNotreported

USUSNationalInstitutesofHealth

USUSNationalInstituteofAllergyand InfectiousDiseases(National InstitutesofHealth)

RussiaRussiaOpenSocietyFoundation

CanadaBritish Columbia CanadianInstitutesofHealth Research,NaturalScienceand EngineeringResearchCouncil ofCanada

CanadaBritish Columbia BritishColumbiaGovernment, CanadianInstitutesofHealth Research,NaturalScienceand EngineeringResearchCouncil ofCanada,MichaelSmith FoundationforHealth Research,NationalInstitutes ofHealth

IrvineMA2022Literature, Modiﬁed-Delphi panel USUSNationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

LanghamS2018Literature, Assumption UKUKMundipharmaInternationalLtd.

LinasBP2021Surveillancedata, Literature, Assumption USRural,urban Massachusetts NationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

UyeiJ2017Surveillancedata, Literature, Assumption USConnecticutConnecticutDepartmentof PublicHealth,NationalInstitute ofMentalHealth(National InstitutesofHealth)

System dynamics model Stringfellow EJ 2022Surveillancedata, Literature, Expertinput, Assumption USUSUSFoodandDrug Administration

Meta-analysisMcAuleyA2015OENDprogram studies Canada, UK,US n/aNationalHealthService Scotland

SpatialanalysisRoweC2016SurveillancedataUSSanFranciscoNationalInstituteonDrug Abuse(NationalInstitutes ofHealth)

YiG2022SurveillancedataUSBaltimoreNotreported

urbanandruralMassachusettspopulationsalsousingthe 2018Irvineetalmodel.16,17

Theonestudyusingasystemdynamicsmodelwas conductedbyStringfellowetalin2022andinvestigatedthe effectsofdifferentinterventions,includingnaloxone distribution,onopioidoverdosedeathrates.18

Mathematicalmodelsemployedvariousdatasourcesto informtheparametersused.Thesesourcesincluded parametersfrompublishedliteratureandsurveillancedata (ie,publichealthdepartmentrecords,coronerreports, insuranceclaims).Whensourcesofdatawerenotavailable, authorsusedtheirownassumptionsorexpertinput,

includingamodiﬁed-Delphipanelinthe2022Irvineetal study.16 Thestudiesdonotapplythemathematicalmodelsto anyspeciﬁccitiesorsmallercommunities,althoughthe2021 Linasetalstudymodelsageneralizedruralcityanda generalizedurbancityinMassachusetts.17 Adoptingthe mathematicalmodelsemployedinthesestudiestoestimate bystandernaloxoneadministrationinaparticular communityofinterestwouldrequiretheinputoflocal parameters,whichcouldbeanintensiveeffortifsurveillance infrastructureisnotestablished.

Meta-analysis

OnestudybyMcAuleyetal,publishedin2015,consisted ofameta-analysisofnineOENDprogramstudies, synthesizingtheiroutcomesandaccountingforparticipants losttofollow-uptoreporttheproportionofnaloxonekits thatarelikelytobeusedinthe ﬁrstthreemonthsafter distribution.19 Thestudiesthatcomprisedthemeta-analysis werefromCanada,theUnitedKingdom,andtheUS. Adoptingameta-analysismethodologytoestimate bystandernaloxoneadministrationinaparticular communityofinterestwouldinvolvesynthesizingdatafrom OENDprogramsinthecommunity.

SpatialAnalysis

Twostudies,byRoweetal(2016)andYietal(2022),used geographicsysteminformation(GSI)mappingtechnologyto conductspatialanalysisofnaloxoneoverdoseincidents.The studiesdeterminedtherelationshipbetweenproximityofthe censustractinwhichnaloxonewasadministeredandthe nearestnaloxonedistributionsite.20,21 Roweetalconducted ananalysisofSanFrancisco,California,andYietal conductedananalysisofBaltimore,Maryland.Surveillance datawasusedtoestablishthisrelationship.TheGSI mappingandspatialanalysismethodologyusedinthese studiescouldbeadoptedinotherjurisdictionstoestimate bystandernaloxoneadministrationinaparticular neighborhoodofinterestbasedinpartondistancefrom naloxonedistributionpoints.

DISCUSSION

LimitedMethodstoEstimateTake-homeNaloxoneUse

Thelimitednumberofstudiescapturedinthisscoping reviewevidencesthelackofsurveillanceandestimation methodsfortheadministrationofTHN,outsideofOEND programrecordsbasedonself-reports.Ofthemethodsused, mathematicalmodelingandmeta-analysisprovideddirect estimationsoftheproportionofdistributednaloxone administered;however,bothmethodswereappliedonlyover largegeographicareas(entirecountries,statesorprovinces, amalgamatingdifferentcitiesaroundtheglobe)or theoreticalcitiesrepresentingalargegeographicarea (“urbancityofMassachusetts”).

Mathematicalmodelingwasthemostpopularformof estimatingadministrationofnaloxonebycommunity members.Further,thepopularityofmodelingincreased relativetotheothermethods.Whilemakingup79%ofstudy methodologiesfoundoverall,itcomprises89%ofstudiesin the ﬁveyearsfrom2018–2022,asshownin Figure2.Reasons forthepopularityofmathematicalmodelsmaybe convenience,includingtheuseofexpertinputand assumptionsforunknownparameters,andtheabilityto tailormodelstodifferentgeographicareasbyadjusting parameters.Nineofthe11modelingstudiesusedoneoftwo modelbases,CofﬁnandSullivan(2013)and Irvineetal(2018).9,14

Therelativedisuseofmeta-analysismaybeexplainedby thelowerpracticalvalueofnaloxoneadministrationdata averagedovermultiplelocations,asopposedtoapplying localdatatoinformprogramgrowthandgaugeimpact. Meta-analysisofnaloxoneuseinothercommunitiesmaybe informativeinjurisdictionslackingtheirownsurveillance data,butcaremustbeexercisedinselectingwhich communitiesandprogramstouseasreferences.Thespread ofOENDprograms,however,mayprovideanopportunity formoreapplicablecomparisons.Further,largeproportions offollow-uplossareevidencedinsomeOENDprograms, addinguncertaintytometa-analysisresults;threeofthenine OENDprogramsthatMcAuleyetal(2015)usedintheir analysishadthree-monthfollow-upratesoflessthan70% (eg,34%,30%,23%).19

Spatialanalysisyieldedarelationshipbetweennaloxone administrationanddistancefromnaloxonedistribution point.Bothstudiesincludedinthisscopingreview(Rowe etal2016,andYietal2022)werereliantuponself-reported datafromOENDprograms.Thisdata,whichisneededto constructaGSImap,maybeusefulforidentifying geographicareasforinterventionbutmaybelessusefulfor extrapolationtounreportedTHNuse.Further,onlythe studybyYietal(2022)characterizedtherelationship betweenprobabilityofbystandernaloxoneadministrationat

Figure2. Methodsusedovertime.

anoverdoseanddistancefromdistributionpoint.21 Rowe etal(2016)insteadreportedtotalnumberofadministration eventsasafunctionofdistance,furtherlimitingexternal validityoftheresults.20

OpioidEducationandNaloxoneDistributionPrograms

WhileweexcludedindividualOENDprogram-based studiesfromthisscopingreview,theyareimportantfor discussionandcomprised59ofthecapturedarticlesinthe systematicsearch.Datafromtheseprograms,whetherornot publishedinpeer-reviewedjournals,isthefoundationforthe parametersinmathematicalmodels,thecomponentstudies ofmeta-analysis,andthelocationdataforspatialanalysis. Theaccuracyofallmethodstoestimatenaloxone administrationbybystanderswrapsbackaroundtothe qualityofself-reporteddatafromOENDprograms.When estimationsofTHNuseareputforwardtoinformpolicy,the methodsbehindtheestimatemustbejustiﬁablybetterthan localOENDdata,ifavailable.Amalgamateddataprovided bygovernmentinstitutionsandnationalcoalitionsmayalso beavailablebutwilllacklocalspeciﬁcity.22,23

LIMITATIONS

Therearelimitationstothisscopingreviewandits applicability.Inourstudywedidnotattempttoinclude methodspublishedinthegrayliteratureinourinitialsearch strategy.Thislimitationwasaddressedinpartthrough informalpreliminarysearches,correspondencewithpublic healthpersonnelattheCaliforniaDepartmentofPublic HealthandtheCABridgeprogram,andcitationsearching. Further,itwasnotexpectedthatmethodsforestimationof bystandernaloxoneusewouldexistwithoutbeingpublished inpeer-reviewedjournals.

Arelatedlimitationofthisstudyisthattheinitialsearch forrelevantarticleswaslimitedtothePubMeddatabase. ThisdecisionwasbasedonthePubMedsearchterms comprehensivelycapturingallstudiesidentiﬁedbyprevious informalpreliminarysearchesandcorrespondencewith publichealthpersonnel.Additionally,thesearchstrategy attemptedtocaptureanypotentiallymissedliterature throughbackwardscitationsearching,andtheabsenceof anynewrelevantarticlessupportedtheparametersofthe initialsearch.

Anotherlimitationtothisscopingreviewisthatitdidnot attempttoascertainthecomparativevalueofmethodsused inestimatingbystandernaloxoneuse.Itispossiblethat preferredmethodsfordeterminingbystandernaloxoneuse willbedependentuponintendeduseoftheanalysisand preferenceforrisk.MethodshighlyinﬂuencedbyOEND programdatawillinherentlyprovideunderestimation, whileothersmaycauseoverestimation.Finally,the environmentsurroundingharmreductionisconstantly changing.TherecentapprovalofOTCnaloxoneisanew

policythatthestudiescapturedinourreview donotaddress.

CONCLUSION

Thepresentscopingreviewdescribestheavailable methodsforestimatingbystanderadministrationof naloxone.Mathematicalmodels,particularlyMarkov models,aremostcommon.Systemdynamicsmodeling, meta-analysis,andspatialanalysishavealsobeenused.All methodsareheavilydependentuponOENDprogramdata publishedintheliteratureoravailableasongoing surveillancedata.Overall,thereisapaucityofliterature describingmethodsofestimation,andofthesefewhavebeen appliedwithalocalfocus.Thisisofconcernasharm reductionisstillregardedwithstigma.Further,evenas naloxonedistributionbecomesmorenormalized,both politicallyandsocially,effectivedistributionwillremain importantinalandscapeoffundingandresourcescarcity withcomplementaryinterventionsandcompeting policypriorities.

AddressforCorrespondence:BharathChakravarthy,MD,MPH, UniversityofCaliforniaIrvine,SchoolofMedicine,Departmentof EmergencyMedicine,3800WChapmanAve.,Suite3200,Orange, CA92868.Email: bchakrav@hs.uci.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thepresentscopingreviewwas researcherfunded.Therearenoconflictsofinterestorsourcesof fundingtodeclare.

REFERENCES

1.CaliforniaDepartmentofHealthCareServices.Naloxone distributionproject.2023.Availableat: https://www.dhcs.ca.gov/ individuals/Pages/Naloxone_Distribution_Project.aspx AccessedMarch22,2023.

2.MartignettiLandSunW.Perspectivesofstakeholdersofequitable accesstocommunitynaloxoneprograms:aliteraturereview. Cureus. 2022;14(1):e21461.

3.CarrollJJ,GreenTC,NoonanRK.Evidence-basedstrategiesfor preventingopioidoverdose:what’sworkingintheUnitedStates. CDC 2018.Availableat: http://www.cdc.gov/drugoverdose/pdf/pubs/ 2018-evidence-based-strategies.pdf.AccessedMarch22,2023.

4.TriccoAC,LillieE,ZarinW,etal.PRISMAextensionforscoping reviews(PRISMA-ScR):checklistandexplanation. AnnInternMed. 2018;169(7):467–73.

5.NationalLibraryofMedicine.PubMedoverview.Availableat: https:// pubmed.ncbi.nlm.nih.gov/about/.AccessedMarch29,2023.

6.SonnenbergFAandBeckJR.Markovmodelsinmedicaldecision making:apracticalguide. MedDecisMaking. 1993;13(4):322–38.

7.WangY,HuB,ZhangY,etal.Applicationsofsystemdynamicsmodels inchronicdiseaseprevention:asystematicreview. PrevChronicDis. 2021;18:E103.

8.AcharyaM,ChopraD,HayesCJ,etal.Cost-effectivenessofintranasal naloxonedistributiontohigh-riskprescriptionopioidusers. Value Health. 2020;23(4):451–60.

9.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributingnaloxone toheroinusersforlayoverdosereversal. AnnInternMed. 2013;158(1):1–9.

10.CofﬁnPOandSullivanSD.Cost-effectivenessofdistributingnaloxone toheroinusersforlayoverdosereversalinRussiancities. JMedEcon. 2013;16(8):1051–60.

11.LanghamS,WrightA,KenworthyJ,etal.Cost-effectiveness oftake-homenaloxoneforthepreventionofoverdosefatalities amongheroinusersintheUnitedKingdom. ValueHealth. 2018;21(4):407–15.

12.UyeiJ,FiellinDA,BuchelliM,etal.Effectsofnaloxonedistributionalone orincombinationwithaddictiontreatmentwithorwithoutpre-exposure prophylaxisforHIVpreventioninpeoplewhoinjectdrugs: acost-effectivenessmodellingstudy. LancetPublicHealth. 2017;2(3):e133–40.

13.CofﬁnPO,MayaS,KahnJG.Modelingofoverdoseandnaloxone distributioninthesettingoffentanylcomparedtoheroin. DrugAlcohol Depend. 2022;236:109478.

14.IrvineMA,BuxtonJA,OtterstatterM,etal.Distributionoftake-home opioidantagonistkitsduringasyntheticopioidepidemicinBritish

Columbia,Canada:amodellingstudy. LancetPublicHealth. 2018;3(5):e218–25.

15.IrvineMA,KuoM,BuxtonJA,etal.Modellingthecombinedimpactof interventionsinavertingdeathsduringasynthetic-opioidoverdose epidemic. Addiction. 2019;114(9):1602–13.

16.IrvineMA,OllerD,BoggisJ,etal.EstimatingnaloxoneneedintheUSA acrossfentanyl,heroin,andprescriptionopioidepidemics:amodelling study. LancetPublicHealth. 2022;7(3):e210–8.

17.LinasBP,SavinkinaA,MadushaniRWMA,etal.Projectedestimatesof opioidmortalityaftercommunity-levelinterventions. JAMANetwOpen. 2021;4(2):e2037259.

18.StringfellowEJ,LimTY,HumphreysK,etal.Reducingopioiduse disorderandoverdosedeathsintheUnitedStates:adynamicmodeling analysis. SciAdv. 2022;8(25):eabm8147.

19.McAuleyA,AucottL,MathesonC.Exploringthelife-savingpotentialof naloxone:asystematicreviewanddescriptivemeta-analysisoftake homenaloxone(THN)programmesforopioidusers. IntJDrugPolicy. 2015;26(12):1183–8.

20.RoweC,SantosGM,VittinghoffE,etal.Neighborhood-levelandspatial characteristicsassociatedwithlaynaloxonereversaleventsandopioid overdosedeaths. JUrbanHealth. 2016;93(1):117–30.

21.YiG,DaytonL,UzziM,etal.Spatialandneighborhood-levelcorrelates oflaynaloxonereversaleventsandserviceavailability. IntJDrugPolicy. 2022;106:103739.

22.WheelerE,DavidsonPJ,JonesTS,etal.Community-basedopioid overdosepreventionprogramsprovidingnaloxone UnitedStates, 2010. MMWRMorbMortalWklyRep. 2012;61(6):101–5.

23.WheelerE,JonesTS,GilbertMK,etal.Opioidoverdoseprevention programsprovidingnaloxonetolaypersons UnitedStates,2014. MorbMortalWklyRep. 2015;64(23):631–5.

BRIEF RESEARCH REPORT:OPIOID USE DISORDER

Attitudes,Beliefs,Barriers,andFacilitatorsofEmergency DepartmentNursesTowardPatientswithOpioid

UseDisorderandNaloxoneDistribution

CollinMichels,MD*

ThomasSchneider,BS†

KaitlinTetreault,MB‡

JennaMeierPayne,BSN*

KaylaZubke,MSN,RN*

ElizabethSalisbury-Afshar,MD,MPH§∥

*UniversityofWisconsin,SchoolofMedicineandPublicHealth, BerbeeWalshDepartmentofEmergencyMedicine,Madison,Wisconsin

† UniversityofWisconsin,SchoolofMedicineandPublicHealth, Madison,Wisconsin

‡ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofBiostatisticsandMedicalInformatics, Madison,Wisconsin

§ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofFamilyMedicineandCommunityHealth, Madison,Wisconsin

∥ UniversityofWisconsin,SchoolofMedicineandPublicHealth, DepartmentofPopulationHealthSciences,Madison,Wisconsin

SectionEditor:R.GentryWilkerson,MD

Submissionhistory:SubmittedMarch30,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary16,2024

ElectronicallypublishedMay21,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem

DOI: 10.5811/westjem.18020

Introduction: Asopioidoverdosedeathscontinuetorise,theemergencydepartment(ED)remainsan importantpointofcontactformanyatriskforoverdose.Inthisstudyourpurposewastobetter understandtheattitudes,beliefs,andknowledgeofEDnursesincaringforpatientswithopioiduse disorder(OUD).Wehypothesizedadifferenceintrainingreceivedandattitudestowardcaringfor patientswithOUDbetweennurseswith <5yearsand ≥6yearsofclinicalexperience.

Methods: WeconductedasurveyamongEDnursesinalargeacademicmedicalcenterfromMay–July 2022.AllEDstaffnursesweresurveyed.Dataentryinstrumentsforthenursingsurveyswere programmedinQualtrics,andweanalyzedresultsRusingachi-squaretestorFisherexacttestto comparenurseswith <5yearsand ≥6yearsofclinicalexperience.A P-valueof < 0.05wasconsidered statisticallysigniﬁcant.

Results: Wedistributed74surveys,and69werecompleted(93%).Attitudestowardnaloxone distributionfromtheEDwerepositive,with72%ofrespondentsreportingtheywere “very” or “extremely” supportiveofdistributingnaloxonekitstoindividualsatriskofoverdose.Whileattitudeswerepositive, barriersincludedlimitedtime,lackofsystemsupport,andcost.Levelofcomfortincaringforpatientswith OUDwashigh,with78%ofrespondents “very” or “extremely” comfortable.Moreeducationisneededon overdoseeducationandnaloxonedistribution(OEND)withrespondents38%and45% “alittle” or “somewhat” comfortable,respectively.Nurseswith <5yearsofexperiencereportedreceivingmore trainingonOENDinnursingschoolcomparedtothosewith ≥6yearsofexperience(P = 0.03).There werenosigniﬁcantdifferencesinreportedattitudes,knowledge,orcomfortincaringforpatients withOUD.

Conclusion: Inthissingle-centersurvey,wefoundEDnursesweresupportiveofoverdoseeducation andnaloxonedistribution.Thereareopportunitiesfortargetededucationandaddressingsystemic barrierstoOEND.Allinterventionsshouldbeevaluatedtogaugeimpactonknowledge,attitudes,and behaviors.[WestJEmergMed.2025;26(1.1)33–37.]

INTRODUCTION

Opioidusedisorder(OUD)isassociatedwitha20-fold riskofearlydeathduetooverdose,infection,trauma,or suicide.1 Nationally,anestimated68,000peoplediedof opioid-relatedoverdosein2020,and2.7millionsuffered fromOUD.2 Theimpactofnon-medicalopioiduseand OUDcanbeseeninmanyhealthcaresettings,includingthe emergencydepartment(ED),asopioid-relatedvisitsinthe EDhadanestimatedcostof$1.47billionperyear between2016–2017.2,3

PatientspresentingtotheEDforopioid-related encounters,includingopioidoverdose,areathighriskfor negativeoutcomes.Emergencydepartment-based interventionssuchasoverdoseeducationandnaloxone distribution(OEND)canhaveasigniﬁcantimpacton opioid-relatedmorbidityandmortality.Naloxoneisan opioidreceptorantagonistthatisusedtoquicklyreversethe effectsofopioidoverdose.In2018,theUSSurgeonGeneral recommendedincreasingaccesstonaloxoneforthosewho areatanincreasedriskofanopioidoverdose.4 TheAmerican CollegeofEmergencyPhysiciansalsorecommends providingnaloxoneforpatientsatincreasedriskofopioid overdose,includingthosedischargedfromtheEDafteran opioid-relatedvisitaswellasanypatientwithahistory ofOUD.5

Emergencydepartment-basedtake-homenaloxone programshavebeenaneffectivemeansofdistributing naloxonetopatientsatriskforfutureoverdose6,7;and OENDfromtheEDhasbeenshowntohavepositiveimpact ontrainedlaypersonsinadditiontopatientsandtheirsocial network.8 Large-scaleOENDhasbeenshowntobean effectivepublichealthintervention.9 Patienteducation relatedtooverdosepreventionandnaloxonedistributioncan beprovidedbyEDnurseswhoroutinelyspendmoretime withpatientsthanthetreatingclinician.Clinicalnurse specialist-ledOENDintheEDhavebeeneffectiveacrossan integratedhealthcaresystem.10 Whilemuchisknownabout thebeliefs,attitudes,andbarriersofprescriberstoward naloxonedistribution,includingtime,cost,andclinical decisionsupport,lessisknownaboutnurseperspectivesin theED.6,7,11–15 Wesoughttoevaluatenurseattitudes, beliefs,barriers,andfacilitatorstonaloxonedistributionin anacademicEDintheMidwest.

METHODS

FromMay–July2022weconductedasurveyofEDnurses ataquaternary-care,academicEDintheMidwestthatsees approximately60,000patientsperyear.Theresearchteam, whichincludedanemergencyphysicianandanaddiction medicinephysician,createdasurveytoolincollaboration withsurveymethodologyexpertsfromtheUniversityof WisconsinSurveyCenter.Mostitemsonthesurveywere developedbytheteam,butthestigmaquestionswere adaptedfromavalidatedmentalhealthstigmasurvey.15–17

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartmentsplayacrucialrolein caringforpatientswithopioidusedisorder (OUD)withinterventionssuchasoverdose educationandnaloxonedistribution.

Whatwasthemajorresearchquestion?

WhatareattitudesofEDnursesrelatedto caringforpatientswithOUD,andtrainingin overdoseeducationandnaloxone distribution(OEND)?

Whatisthemajor ﬁndingofthestudy?

EDnurseshavepositiveattitudes(72%) towardnaloxonedistribution.Earlycareer nurses( < 5years)hadmoreOENDtraining.

Howdoesthisstudyimprove populationhealth?

Resultshighlightopportunitiesfortargeted nursingeducation,addressingbarriersand facilitatorstoOENDintheED,thereby improvingcareforpatientswithOUD.

ResearchcoordinatorsintheEDdistributed74paper surveystofullandpart-timeEDstaffnursesatdailystaff huddlesduringthestudyperiod.Eachrespondentwas allowedtocompleteonlyonesurvey.A$5pre-incentivewas includedwiththesurveyatthetimeofdistribution.

Weusedachi-squaretestorFisherexacttesttoassessthe differenceinnurseattitudes,basedonrelativejobexperience (≤5yearsv ≥6years),regardingperception,knowledge,and barriersfornaloxonedistributionandcaringforpatients withOUD.AllanalysesweredoneinRv4.1.12021 (RFoundationforStatisticalComputing,Vienna,Austria). A P -valueof <0.05wasconsideredstatisticallysigniﬁcant.

Disclosures

ThisstudywasreviewedbytheUniversityofWisconsinMadisonMinimalRiskResearchInstitutionalReview Boardanddeemedexempt.Noneoftheauthorshaveany ﬁnancialconﬂictsofinteresttodisclose.

RESULTS

Surveysweredistributedto74EDnurses,witha93% responserate.Respondentshadabreadthofclinical experience,with60%havingbeenapracticingnurseforsix yearsormore.Ofthatgroup,21%hadbeenapracticing

nursefor ≥16years.ThemajorityoftheEDnursesreported completingtheirnursingtrainingintheMidwest(83%). OtherregionsrepresentedweretheWest(7.6%),Southwest (1.5%),Southeast(4.5),andNortheast(3%).

Overall,theleveloftrainingonOENDduringnursing schoolwaslow,with77%reportingnooralittleeducation received.Nurseswith0–5yearsofexperiencereported receivingmoreeducationcomparedtonurseswith ≥6years ofexperience(P = 0.03).Whenaskedaboutlevelofcomfort providingeducationrelatedtonaloxoneforoverdose preventionimmediatelyfollowingnursingschool,67%felt “notatall” or “onlyalittle” prepared.Despitemorerecent nursingschoolgraduatesreportingmoreeducationin nursingschool,therewerenodifferencesinhowprepared theyfelttoprovideOEND(P = 0.63).

Responsesweremixedwhentheywereaskedaboutthe perceivedeffectivenessofnaloxonekitsasapublichealth intervention,with55%ofallnursesreportingnaloxonekits are “alittle” or “somewhat” effective.However,themajority (66%)feltthatnaloxonekitswouldnotincreasebehavior thatputpeopleatriskforoverdose.Additionalresponsesto questionsaboutattitudes,beliefs,barriers,andfacilitatorsto naloxonedistributionfromtheEDareavailableinthe Table Responsestoallquestionswerecomparedbetweenthenurses with0–5years’ experiencetothosewith ≥6years’ experience, andnostatisticallysigniﬁcantdifferenceswereappreciated.

Overallcomfortlevelforcaringforpatientswhousenonprescribedopioidswashigh,with78%ofrespondentsveryor extremelycomfortable.Again,nodifferenceswere appreciatedbetweennurseswith0–5years’ experienceand thosewith ≥6years’ experience.

Barriersandfacilitatorstonaloxonedistributioninthe EDarevariedandrelatedtotime,education,andcost concerns.Staffreportedthemostsigniﬁcantbarrierwas limitedstafftime,with47%reportingthiswasan “extremely” impactfulbarrier.Thesearesimilarto previouslydescribedbarriersandfacilitatorsthatprescribers reportfacing;responsesareincludedinthe Table 14–18

DISCUSSION

Emergencydepartmentnursesarecriticaltothe effectivenessofED-basedOENDprograms.Althoughthere havebeenmultiplestudieslookingatemergencyclinician attitudes,beliefs,barriers,andfacilitatorstonaloxone distribution,littleisknownaboutEDnurse-speciﬁcfactors forOEND.Althoughnursesinpracticefor ≤5yearsreported receivingmoreeducationonnaloxoneforoverdose preventionwhileinnursingschool,theadditionaleducation didnotrelatetostatisticallysigniﬁcantdifferencesin attitudes,comfort,orperceivedbarriersorfacilitators. Furtherresearchisneededtoprovideabetterunderstanding ofwhyreceivingmoreeducationdidnotleadtoincreased

Table. Responsesofemergencydepartmentnursestoquestionsaboutattitudes,beliefs,barriers,andfacilitatorstonaloxonedistribution fromtheED. NotatallAlittleSomewhatVeryExtremely

AttitudesHowmuchdoyousupportgivingnaloxonekitsto individualswhomightbeatriskforopioidoverdose?

Howeffectiveisgivinganaloxonekittopeoplewho usedrugsasapublichealthintervention?

Howlikelyisgivinganaloxonekittopeoplewhouse drugsgoingtoleadtobehaviorsthatincreaseriskfor overdose,eg,usingmoreopioidsorusingin combinationwithotherdrugs? 41.8%(28)23.9%(16)25.4%(17)9.0%(6)0.0%(0)

ComfortAskingscreeningquestionsaboutnon-prescribed opioiduse?

Caringforpatientswhousenon-prescribedopioids?0.0%(0)1.4%(1)20.3%(14)46.4%(32)31.9%(22) Offeringanaloxonekittobeabletoreversean overdose?

1.4%(1)5.8%(4)33.3%(23)31.9%(22)27.5%(19)

Teachingalaypersontoadministernaloxone?2.9%(2)10.1%(7)27.5%(19)34.8%(24)24.6%(17) Providingcaretoapersonwithanopioiduse disordercomparedtohelpingapersonwitha physicalillness?

Educatingpatientsaboutopioidoverdose prevention?

Educatingpatientsaboutoverdoseresponseand naloxoneadministration?

3.0%(2)4.5%(3)26.9%(18)47.8%(32)17.9%(12)

0.0%(0)5.8%(4)36.2%(25)44.9%(31)13.0%(9)

4.3%(3)15.9%(11)29.0%(20)37.7%(26)13.0%(9)

Educatingpatientsaboutoverdoseprevention?2.9%(2)18.8%(13)30.4%(21)34.8%(24)13.0%(9) (Continuedonnextpage)

Table. Continued.

NotatallAlittleSomewhatVeryExtremely BarriersLimitedstafftime?0.0%(0)4.5%(3)18.2%(12)30.3%(20)47.0%(31)

Lackofsystemssupportingittohappeninatime efﬁcientway?

Lackofclinicaldecisionsupporttoensureconsistent process?

Howmuchofabarriertodispensingnaloxonekits fromtheEDislackofinsuranceorlimitedinsurance coverageleadingtohighcoststopatients?

Concernsaboutbeingabletoidentifypatientsatrisk foroverdose?

Concernsthatalaypersonwon’tbeableto administeritappropriately?

Concernsthatprovidinganaloxonekitwillleadto moreorriskierdruguse?

Concernsthatpatientswillbeoffendedbyitbeing offered?

1.5%(1)4.6%(3)21.5%(14)43.1%(28)29.2%(19)

31.%(2)10.9%(7)25.0%(16)39.1%(25)21.9%(14)

9.4%(6)10.9%(7)17.2%(11)39.1%(25)23.4%(15)

FacilitatorsFundingtoensurepatientsdon’thavetopayco-pays forcostofthenaloxonekit? 3.1%(2)7.8%(5)20.3%(13)32.8%(21)35.9%(23)

Clinicaldecisionsupportthatmakestheprescription anautomatedprocess?

Educationforstaff?1.6%(1)3.1%(2)43.8%(28)35.9%(23)15.6%(10)

Howmuchofafacilitatortodischargingapatient fromtheEDwithanaloxonekitispatienteducation materialstoteachaboutoverdosepreventionand naloxoneadministration?

ED,emergencydepartment.

comfortorknowledgeandwhetherofferingmoretargeted educationcanimprovethesemetrics.Despitereceivingmore education,earlycareernurseshavehadlessexperiencecaring forpatientswithOUD,whichmayhavecontributed totheresults.

Overall,mostrespondentswerecomfortablecaringfor patientswithOUD,includingaskingOUDscreening questions.Slightlylessthanhalffeltnaloxoneisa “ very ” or “extremely” effectivepublichealthintervention,whichisan importantareaforfutureeducationaleffortsandevaluation. Additionalareasforeducationalfociincludetrainingson overdosepreventioneducationandnaloxonetrainingfor patientsandtheirfriends/familywhileintheED.Thisdata providesabaselineunderstandingandcanbere-assessed afterfurthereducationalinitiatives.

Wefoundnursing-identiﬁedbarriersweresimilarto previouslydescribedprescriberbarriersincludinglimited time,cost,andlackofefﬁcientsystemsupport.18–20 Someof thesebarrierscanbeaddressedwithclinicaldecisionsupport, includingpromptstoordernaloxoneforpatientswith opioid-relateddiagnosticcodes.Providingstandardized, easy-to-followinstructionsonoverdosepreventionand

3.2%(2)7.9%(5)27.0%(17)44.4%(28)17.5%(11)

naloxoneadministrationcanbeneﬁtboththepatientsand thestaffmemberprovidingtheeducation.Although handoutsarehelpful,regulareducationbycontentexperts wouldprovidecontinuededucationtoensureallstaffare comfortablewithoverdosepreventioneducationand naloxoneusemovingforward.

Overall,EDnurseswereopentoreceivingmore education,andmostnursesidentiﬁedthisasafacilitatorto expandingnaloxonedistributionintheED.Usingbaseline surveysliketheoneourteamusedcanguideEDleadership whendevelopingeducationalandsystemsinterventionsfor nursingstaff.

LIMITATIONS

Limitationsofthisstudyincludeevaluatingasingle, academicLevelItraumacenter;soresultsmaynotapply morebroadlytootherEDs.Wedidnotevaluatefornursing experienceinareasoutsidetheED.Additionally,thenumber ofEDnursessurveyedwassmall(69);soitispossiblethatthe samplesizewastoosmalltoenableustoidentifydifferences betweenthenurseswithlessexperienceascomparedtothose withmoreexperience.

CONCLUSION

Understandingattitudes,beliefs,barriers,andfacilitators ofnaloxonedistributionamongEDnursesisimportantfor successfulimplementationofoverdoseeducationand preventionprogramming.Emergencydepartmentnurses surveyedweregenerallysupportiveofnaloxonedistribution andcomfortablecaringforpatientswithOUD.Thereare opportunitiesforaddressingsystemicbarriersandproviding targetededucationtofacilitateED-basednaloxone distribution.Theseresultsshowopportunitiestoimprove careforpatientswithOUD,althoughfutureresearchis neededtodeterminewhethereducationimpactsknowledge, attitudes,andbehaviors.

AddressforCorrespondence:CollinMichels,MD,Universityof Wisconsin,SchoolofMedicineandPublicHealth,BerbeeWalsh DepartmentofEmergency,800UniversityBayDr.,Suite310, Madison,WI53705.Email: ctmichels@medicine.wisc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thisworkwassupportedbythe UniversityofWisconsinDepartmentsofFamilyMedicineand CommunityHealthandPopulationHealthSciencesaswellasthe UniversityofWisconsinBerbeeWalshDepartmentofEmergency Medicine.Therearenootherconflictsofinterestorsourcesof fundingtodeclare.

REFERENCES

1.NationalAcademiesofSciences,Engineering,andMedicine. MedicationsforOpioidUseDisorderSaveLives.WashingtonDC:The NationalAcademiesPress,2019.

2.SubstanceAbuseandMentalHealthServicesAdministration.Key SubstanceUseandMentalHealthIndicatorsintheUnitedStates: Resultsfromthe2020NationalSurveyonDrugUseandHealth. 2022.Availableat: https://www.samhsa.gov/data/sites/default/ﬁles/ reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/ 2020NSDUHFFR1PDFW102121.pdf.AccessedJanuary20,2023.

3.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

4.OfﬁceoftheSurgeonGeneral.U.SSurgeonGeneral’sAdvisoryon NaloxoneandOpioidOverdose.2022.Availableat: https://www.hhs. gov/surgeongeneral/reports-and-publications/addiction-andsubstance-misuse/advisory-on-naloxone/index.html AccessedJanuary10,2023.

5.DuberHC,BarataIA,Cioè-PenaE,etal.Identiﬁcation,management, andtransitionofcareforpatientswithopioidusedisorderinthe emergencydepartment. AnnEmergMed. 2018;72(4):420–31.

6.EswaranV,AllenKC,CruzDC,etal.Developmentofatake-home naloxoneprogramatanurbanacademicemergencydepartment. JAM PharmAssoc. 2020;60(6):324–31.

7.EswaranV,AllenKC,BottariDC,etal.Take-homenaloxoneprogram implementation:lessonslearnedfromsevenchicago-areahospitals. AnnEmergMed. 2020;76(3):318–27.

8.DwyerK,WalleyA,LangloisB,etal.Opioideducationandnasal naloxonerescuekitsintheemergencydepartment. WestJEmergMed. 2015;16(3):381–4.

9.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxonedistributionin Massachusetts:interruptedtimeseriesanalysis. BMJ. 2013;346:f174.

10.MullennixSC,IselerJ,KwiatkowskiGM,etal.Aclinicalnursespecialistledemergencydepartmentnaloxonedistributionprogram. ClinNurse Spec. 2020;34(3):116–23.

11.LowensteinM,KilaruA,PerroneJ,etal.Barriersandfacilitatorsfor emergencydepartmentinitiationofbuprenorphine:aphysiciansurvey. AmJEmergMed. 2019;37(9):1787–90.

12.HawkKF,D’OnofrioG,ChawarskiMC,etal.Barriersandfacilitatorsto clinicianreadinesstoprovideemergencydepartment-initiated buprenorphine. JAMANetwOpen. 2020;3(5):e204561.

13.EllisK,WaltersS,FriedmanSR,etal.Breachingtrust:aqualitative studyofhealthcareexperiencesofpeoplewhousedrugsinarural setting. FrontSociol. 2020;5:593925.

14.LacroixL,ThurgurL,OrkinAM,etal.Emergencyphysicians’ attitudes andperceivedbarrierstotheimplementationoftake-home naloxoneprogramsinCanadianemergencydepartments. CJEM. 2018;20(1):46–52.

15.KassamA,PapishA,ModgillG,etal.Thedevelopmentand psychometricpropertiesofanewscaletomeasurementalillness relatedstigmabyhealthcareproviders:theOpeningMindsScalefor HealthCareProviders(OMS-HC). BMCPsychiatry. 2012;12:62.

16.EzellJM,WaltersS,FriedmanSR,etal.Stigmatizetheuse,notthe user?Attitudesonopioiduse,druginjection,treatment,andoverdose preventioninruralcommunities. SocSciMed. 2021;268:113470.

17.KellyT,HawkK,SamuelsE,etal.Improvinguptakeofemergency department-initiatedbuprenorphine:barriersandsolutions. WestJ EmergMed. 2022;23(4):461–7.

18.BarbourK,McQuadeM,SomasundaramS,etal.Emergencyphysician resistancetoatake-homenaloxoneprogramledbycommunityharm reductionists. AmJEmergMed. 2018;36(11):2110–2.

19.PenmJ,MacKinnonNJ,LyonsMS,etal.Combattingopioidoverdoses inOhio:emergencydepartmentphysicians’ prescribingpatternsand perceptionsofnaloxone. JGenInternMed. 2018;33(5):608–9.

20.LaneBH,LyonsMS,StolzU,etal.Naloxoneprovisiontoemergency departmentpatientsrecognizedashigh-riskforopioidusedisorder. AmJEmergMed. 2021;40:173–6.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

ImprovingHealthcareProfessionals’ AccesstoAddiction MedicineEducationThroughVHAAddictionScholarsProgram

ZahirBasrai,MD*

ManuelCeledon,MD*

NathalieDieujuste,MA†

JulianneHimstreet,PharmD§ JonathanHoffman,PharmD∥ CassidyPfaff,PharmD¶ JonieHsiao,MD*

RobertMalstrom,PharmD# JasonSmith,PharmD**

MichaelRadeos,MD,MPH†† TerriJorgenson,RPh‡‡

MelissaChristopher,PharmD§§ ComillaSasson,MD,PhD†‡

*VAGreaterLosAngelesHealthCareSystem,VeteransHealthAdministration, DepartmentofEmergencyMedicine,LosAngeles,California

† VAEasternColoradoHealthCareSystem,VeteransHealthAdministration, Aurora,Colorado

‡ UniversityofColorado,AnschutzMedicalCampus,Aurora,Colorado

§ VAPharmacyBeneﬁtsManagementAcademicDetailingService, Eugene,Oregon

∥ VAVISN19RockyMountainNetwork,SaltLakeCity,Utah

¶ VISN19AcademicDetailingService,VeteransHealthAdministration, Tulsa,Oklahoma

# VAPharmacyBeneﬁtsManagementAcademicDetailingService, Martinez,California

**VISN19AcademicDetailingService,VeteransHealthAdministration, Denver,Colorado

†† NYCHealth + Hospitals/ConeyIsland,DepartmentofEmergencyMedicine, Brooklyn,NewYork

‡‡ PharmacyBeneﬁ tsManagement,ClinicalPharmacyPracticeOfﬁce, Washington,DC

§§ VAPharmacyBeneﬁtsManagementAcademicDetailingService, SanDiego,California

SectionEditor:R.GentryWilkerson,MD

Submissionhistory:SubmittedFebruary2,2023;RevisionreceivedJanuary26,2024;AcceptedFebruary16,2024

ElectronicallypublishedMay20,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.17850

Introduction: Theseeminglyinexorableriseofopioid-relatedoverdosedeathsdespitethereduced numberofCOVID-19pandemicdeathsdemandsnovelresponsesandpartnershipsinourpublichealth system’sresponse.Addictionmedicineispracticedinabroadrangeofsiloedclinicalenvironmentsthat needtobeincludedinaddictionmedicinetrainingbeyondthetraditionalfellowshipprograms.Our objectiveinthisprojectwastoimplementaknowledge-based,livevirtualtrainingprogramthatwould providecliniciansandotherhealthcareprofessionalswithanoverviewofaddiction,substanceuse disorders(SUD),andclinicaldiagnosisandmanagementofopioidusedisorder(OUD).

Methods: TheVeteransHealthAdministration(VHA)EmergencyDepartmentOpioidSafetyInitiative (EDOSI)offeredafour-daycourseforhealthcareprofessionalsinterestedingainingknowledgeand practicalskillstoimproveVHA-basedSUDcare.Thecoursetopicscenteredaroundthediagnosisand treatmentofSUD,withafocusonOUD.Additionally,traineesreceivedsixmonthsofsupporttodevelop addictionmedicinetreatmentprograms.Evaluationsofthecoursewereperformedimmediatelyafter completionoftheprogramandagainatthesix-monthmarktoassessitseffectiveness.

Results: Atotalof56cliniciansandotherhealthcareprofessionalsparticipatedintheAddictionScholars Program(ASP).TheparticipantsrepresentednineVeteranIntegratedServiceNetworksand21different VHAmedicalfacilities.Nearly70%ofparticipantscompletedtheinitialpost-survey.Thirty-eight respondents(97.4%)felttheASPseriescontainedpracticalexamplesandusefulinformationthatcould beappliedintheirwork.Thirty-eightrespondents(97.4%)felttheworkshopseriesprovidednew informationorinsightsintothediagnosisandtreatmentofSUD.Elevencapstoneprojectsbasedonthe

informationacquiredduringtheASPwerefunded(atotalof$407,178).Twentyparticipants(35.7%) completedthesix-monthfollow-upsurvey.Notably,90%ofrespondentsreportedincreasednaloxone prescribingand50%reportedincreasedprescribingofbuprenorphinetotreatpatientswithOUDsince completingthecourse.

Conclusion: TheASPprovidedhealthcareprofessionalswithinsightintomanagingSUDandequipped themwithpracticalclinicalskills.Thestudentstranslatedtheinformationfromthecoursetodevelop medicationforopioidusedisorder(M-OUD)programsattheirhomeinstitutions.[WestJEmergMed. 2025;26(1.1)38–42.]

INTRODUCTION

Thenationalopioidepidemicisoneoftheleading preventablecausesofmorbidityandprematuredeathinthe UnitedStates.In2017,theUSDepartmentofHealthand HumanServices(HHS)declaredtheopioidcrisisapublic healthemergency.1 TheCOVID-19pandemichas exacerbatedthiscrisiswithanincreasedprevalenceofopioid usedisorder(OUD)anddeathsfromprescriptionandnonprescriptionopioids.2 Veteransareatnearlytwicetheriskof fataldrugoverdosewhencomparedtonon-veterans.3 As partofthe ﬁveprioritiestocombattheopioidcrisisHHS highlightedtheimportanceofimprovingaccessto prevention,treatment,andrecoverysupportservices.1 However,thereremaincriticalshortagesofhealthcare professionalswhocanprovidetheselife-savingservices.4 Improvingaccesstosubstanceusedisorder(SUD)careat anytime,anyplaceisanimportantpartoftheVeterans HealthAdministration’s(VHA)strategy.Asaresult,thereis agrowingneedfortraininghealthcareprofessionalsoutside thetraditionaladdictionmedicinespecialtyonkey componentsofaddictionmedicineandSUD.

TheVHAisAmerica’slargestintegratedhealthcare system,providingcareat1,298healthcarefacilitiesincluding 171medicalcentersand1,113VHAoutpatientclinics.More thanninemillionenrolledveteransareservedbytheVHA eachyear.5 Despiteitssize,theVHAsystemhasashortageof addictionspecialistsandSUDclinics.Asaresult,the responsibilityofprovidingSUDcarefallsonavarietyof specialties,includingpharmacyandmentalhealth,and primarycareandemergencymedicine.However,the educationopportunitiesforthesepractitionerstoobtain advancedtraininginaddictionmedicineislimited.

Currently,addictionmedicineisnotarequiredgraduate medicaleducationcourseforinternalmedicine,family medicine,oremergencymedicineresidencies.Asaresult, traineesreceivevariableexposuretoSUDcareduring residency,leadingtosuboptimalpreparationmanaging patientswithaddictionwhenpracticingindependently.6,7 Thetraditionalpathwayforaddictionmedicinetrainingisto completea12-monthdedicatedfellowshipatoneofthe90

sitesaccreditedbytheAccreditationCouncilforGraduate MedicalEducation.8 Thissigniﬁcantcommitmentlimitsthe abilityforfrontlineclinicianstoobtainfurthertrainingin addictionmedicine.Thereisaneedtocreateaccessible didacticandpracticalclinicaleducationinaddiction medicinetoincreasefrontlinecliniciancomfort.

LackofbasictraininginSUDisasigniﬁcantbarrierto physicianengagementofmedicationforopioidusedisorder (M-OUD)programs.9,10 Asaresult,theAddictionScholars Program(ASP)wasdevelopedtoprovideadditionaltraining forphysicianassistants,nursepractitioners,clinical pharmacists,academicdetailingpharmacists,and physicians.Theeducationaltopicsincludedafoundational understandingofthetreatmentofOUD,complexpain,and complexpersistentopioiddependence.Ourobjectiveinthis studywastomeasuretheeffectiveness,immediatelyandat sixmonths,ofahybrideducationalinterventionpairedwith creationofmultidisciplinaryteamsonknowledgeretention andwillingnesstoprescribeM-OUD.

METHODS

Thiswasapost-implementationstudyoftheASP,anovel hybrideducationalapproachandfacilitated,team-based qualityimprovement(QI)project.Surveyswereperformed attheconclusionofthecourseandatthesix-monthmark. Thesurveysfocusedonthecourse’seffectivenessandthe trainee’swillingnesstoinitiateanaddictionmedicineproject attheirsite.Weuseddescriptivestatisticstointerpretthe resultsofthesurvey.TheEmergencyDepartmentOpioid SafetyInitiative(EDOSI)programwasdesignatedasaQI projectthroughtheOfﬁceofPharmacyBeneﬁts ManagementAcademicDetailingServicefromthe institutionalreviewboardoftheEdwardHines,Jr.VA HospitalandapprovedbytheRockyMountainRegional VAMedicalCenterResearchandDevelopmentservice.

AddictionScholarsProgram

TheASPisapartoftheVHAEDOSIandwasdeveloped asanintensivecourseforcliniciansinterestedin understandingVHA-basedSUDcare.Frontlineclinicians

andotherhealthcareprofessionalswhowerecurrent employeesoftheVHAwereinvitedtoapplytoattendthe ASP.Fortywereacceptedtoattendtheprogram.Thecourse consistedoffourvirtualsessionsthatwereeachfourhours long.Eachsessioncoveredfundamentalandadvancedtopics ofaddictionmedicineforemergencyandacutecaresettings.

Theentirecoursewasdeliveredvirtuallyusingthe MicrosoftTeams(MicrosoftCorp,Redmond,WA) application.TopicsincludedclinicalmanagementofOUD, opioidoverdosemanagement,buprenorphineinduction, naloxonedistribution,painmanagementinpatientswith OUD,andopioid-inducedchronicpainsyndrome.The programusedacombinationoflecturesandcase-based breakoutsessionstoreinforcekeyconcepts.Lecturerswere selectedbasedontheirexperienceandexpertiseinspeciﬁc areasofaddictionmedicine.Interdisciplinarygroupswere strategicallyassembledforthecase-basedbreakoutsessions withmembersfromthesameVHAsiteandVeteran IntegratedServiceNetworks(VISN).Thisallowedfora networkingopportunitywheregroupmemberscouldbuild connectionsthatwouldleadtothedevelopmentofM-OUD programslocallyattheirVHAsiteorattheirVISN.The groupswerepairedwithamemberoftheVHAEDOSIteam whowouldfacilitatediscussionofthecases.

Aftersuccessfulcompletionofthecourse,trainees receivedsixmonthsofsupporttodevelopandimplement addictionmedicinetreatmentprograms.Traineeswerealso encouragedtosubmitcapstoneprojects,whichwereeligible forfundingupto$50,000(uptotwoyears)tohelpimplement addictionmedicineprojectsattheirlocalVHAsite.

RESULTS

Atotalof56individualsparticipatedintheASP,including 32clinicians,10clinicalpharmacypractitioners,and14 academicdetailingpharmacists.Thecliniciansrepresented nineVISNsand21differentVHAfacilities.Theclasswas composedof15physicians,sevennursesandnurse practitioners,31pharmacists,andthreephysicianassistants. Participantsrangedinagefrom30–65(mean46.2years)and hadbeeninclinicalpracticeforanaverageof11years (Table1).Additionally,attendeesrepresentednumerous clinicalserviceareasincludingemergencymedicine,urgent care,primarycare,painmanagement,mentalhealth,and substanceusetreatment.

Ofthe56participants,39(almost70%)respondedtothe initialpost-survey.Thirty-eightrespondents(97.4%) reportedthattheASPseriescontainedpracticalexamples andusefulinformationthatcouldbeappliedintheirwork. Thirty-eightrespondents(97.4%)feltthattheworkshop seriesprovidednewinformationorinsightsintothediagnosis andtreatmentofSUD.Thirty-ﬁverespondents(89.7%)were veryorsomewhatsatisﬁedwiththeASPseries. TwentyindividualswhoparticipatedintheASP respondedtothesix-monthfollow-upsurvey.Themajority

Table1. Scholarcharacteristics.

Scholars(%) (N = 32)

Profession Physician15(46.9) Nursepractitioner6(18.8) Nurse1(3.1) Physicianassistant3(9.4) Pharmacist7(21.9) Yearsoutoftraining

0–5years13(40.6) 6–10years6(18.8) 10+ years10(31.3) Missing3(9.4)

ClinicalArea

Emergencydepartmentorurgentcare6(18.8) Mentalhealth,substanceusetreatment, orpsychiatry 14(43.8)

Painmanagement3(9.4) Primarycare5(15.6) Pharmacy1(3.1) Missing3(9.4)

ofrespondents(85.0%)reportedfeeling “comfortable” or “verycomfortable” initiatingM-OUDsincecompletingthe ASP.Fourteen(70%offollowuprespondents)pursued additionalM-OUDtrainingsincecompletingtheASP.Of the20respondents,fourworkedindepartmentswithoutan activeM-OUDprogram;threeofthefour(75%)are currentlyworkingtodevelopanM-OUDprogram.Eighteen (90%)oftherespondentsreportedincreasednaloxone prescribingsincecompletingtheASP.Ten(50%)ofthe respondentsincreasedprescribingofbuprenorphinetotreat patientswithOUDsincecompletingthecourse(Table2).

AttheconclusionoftheASP,11capstoneprojectswere submittedandawardedatotalof$407,178.Seven(63.6%)of theprojectsfocusedonthedevelopmentofnaloxoneor buprenorphineprograms.Otherprojectswerefocusedon harmreductionwiththedevelopmentofasyringeservice program,theuseoffentanyltestingstrips,developmentofa VISN-widevirtuallearningprogramforSUDtraining,urine point-of-caretestingforcontrolledmedications,andmusicandmovement-basedinterventionstoengagehigh-risk veteransinsubstanceusetreatment.

DISCUSSION

OurstudydemonstratedtheASPsuccessfullyprovided additionaladdictionmedicinetrainingtocliniciansandother healthcareprofessionalsandthatthereisadesirefor additionaladdictionmedicinetrainingwithintheVHA

Table2. Resultsofinitialandsix-monthfollow-upsurvey.

Initialfollow-up(N = 39)

TheASPseriescontainedpracticalexamplesandusefulinformationthatcanbeappliedintheirwork.38(97.4%)

TheworkshopseriesprovidednewinformationorinsightsintothediagnosisandtreatmentofSUD.38(97.4%)

“Very” or “somewhat” satisﬁedwiththeASPseries.35(89.7%)

6-monthfollow-up(n = 20)

“Comfortable” or “verycomfortable” initiatingM-OUDsincecompletingtheASP.17(85%)

PursuedadditionalM-OUDtrainingsincecompletingtheASP.14(70%)

WorkindepartmentswithoutanactiveM-OUDprogram.4(20%)

IncreasednaloxoneprescribingsincecompletingtheASP.18(90%)

IncreasedprescribingofbuprenorphinetotreatpatientswithOUDsincecompletingtheASP.10(50%)

ASP,AddictionScholarsProgram; SUD,substanceusedisorder; OUD,opioidusedisorder; M-OUD,medicationforopioidusedisorder.

system.TheASPwasdesignedasaneducationalprogram withanemphasisonpromotingfacility-levelteambuilding toenhancecross-functionalclinicalcare.These ﬁndingsare encouragingas,aftercompletingtheASP,healthcare professionalswithoutformaladdictionmedicinetraining wereabletoadvocateforOUDtreatmentinnon-SUD specialtyclinicalsettingsattheirlocalVHAsite.Successful treatmentofpatientswithOUDrequiresamultidisciplinary approachinvolvingboththeaddictionmedicineserviceand theoutpatientprimarycareteam.Empoweringnon-SUD specialtyclinicswiththeknowledgeandpracticalskillsto treatOUDisessentialinimplementingthe “nowrongdoor” approachtoOUDtreatment.11 Thesupportandnetworking opportunitiesprovidedbytheASPsuccessfullyledtothe developmentoflocaladdictionmedicineprogramsat VHAsitesasevidencedbythe11capstoneprojectsthat werefunded.

ThesuccessoftheASPwasdueinparttotheblended learningstructureofthecourse.Lectureswerecuratedand deliveredbyexpertsinthe ﬁeldandrangedfrombasic addictionmedicinetopicstomoreadvancedtopics.This allowedforengagementofalllearnersregardlessoftheir specialtyorleveloftraining.Thecoursealsoleverageda team-basedlearningapproachthroughthebreakout sessions,whichreinforcedkeycomponentsoftreating complexpatientswithOUD.Team-basedlearninghasbeen showntohavepositiveoutcomesforstudentsintermsof studentexperience.12

Thee-learningplatformalsoallowedforengagementbya wideraudiencethanwouldhaveotherwisebeenpossibleby anin-personcourse.TheASPgaveadditionaladdiction medicinetrainingtothosewhowouldotherwisenothave beeneligibleforafellowshipbythetraditionalpathway.This allowedforengagementofkeystakeholderswhocould implementprogramsatlocalfacilitiesinareasthatare separatefromdedicatedSUDclinics.TheASPisascalable programthatcanbefurtherdevelopedandreplicatedoutside oftheVHAsystem.

LIMITATIONS

Althoughtheprogramdidreceivefavorableratings,itis importanttonotethatattendeesdidself-selecttoattend;asa result,theymayhavebeenmorebiasedintheirratingsofan addictionmedicineprogram.Futureeffortswillbemadeto recruitcliniciansandotherhealthcareprofessionalswhomay beresistantorhesitanttotheadditionofsubstanceuseand opioidsafetymeasuresintheirpractice.Furtherstudiesare neededtoassessactualinterestinadditionaladdiction medicinetrainingthroughouttheVHAsystem.Itshouldbe noted,too,thatthisstudyprovidedonlyasix-monthfollowup,atwhichpointtheparticipants’ surveyresponseratewas low.Additionally,theresultsofthisstudyaresurveybased, andthusthelimitationsthatapplytosurveysalsoapplyhere. Thesurveydidnotcontainknowledge-basedquestionsto assessretentionofknowledge.Futureiterationsofthecourse willcontainknowledge-basedquestionstoassessfor acquisitionofknowledge.Futurestudieswillalsoneedto lookathowtheASPinﬂuencedthedevelopmentofaddiction medicineprogramsintheVHAsystem.Studieswillalsoneed toexaminehowsuccessfulthemanagementofOUDisin nontraditionalsettingsthatareoutsidetheSUDclinics. Futurestudiescanalsobeconductedtocomparelong-term outcomesforpatientswhosehealthcareprofessionals participatedinASPcomparedtothosewhodidnot.

CONCLUSION

ThisfeasibilitystudyhasshownthatASPequipped cliniciansandotherhealthcareprofessionalswithan intensiveoverviewofaddictionmedicine.Thestudents translatedtheinformationfromthecoursetodevelop M-OUDprogramsattheirhomeinstitutions.

AddressforCorrespondence:ZahirBasraiMD,VAGreaterLos AngelesHealthCareSystem,VeteransHealthAdministration, DepartmentofEmergencyMedicine,11301WilshireBLVD, LosAngeles,CA90073.Email: Zahir.basrai@va.gov

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.ComillaSassonMD,PhDisemployed bytheAmericanHeartAssociation.Thisworkwassupportedby CARAfundsthroughthePainManagement,OpioidSafetyand PrescriptionDrugMonitoringProgram(PMOP)Office.Thereareno otherconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.HarganED.DeterminationthataPublicHealthEmergencyExists.2017. Availableat: https://aspr.hhs.gov:443/legal/PHE/Pages/opioids.aspx AccessedJanuary18,2024.

2.USCentersforDiseaseControlandPrevention.IncreaseinFatalDrug OverdosesAcrosstheUnitedStatesDrivenbySyntheticOpioidsBefore andDuringtheCOVID-19Pandemic.2020.Availableat: https://stacks. cdc.gov/view/cdc/98848.AccessedApril25,2021.

3.BohnertAS,IlgenMA,GaleaS,etal.Accidentalpoisoningmortality amongpatientsintheDepartmentofVeteransAffairsHealthSystem. MedCare. 2011;49(4):393–6.

4.DepartmentofVeteransAffairsOfficeofInspectorGeneral.OIG DeterminationofVeteransHealthAdministration’sOccupational StaffingShortagesFiscalYear2021.2021.Availableat: https://www. oversight.gov/sites/default/files/oig-reports/VA/VAOIG-21-01357-271. pdf.AccessedJanuary18,2024.

5.USDepartmentofVeteransAffairs.VeteransHealthAdministration. 2008.Availableat: https://www.va.gov/health/ AccessedApril25,2021.

6.MillerNS,SheppardLM,ColendaCC,etal.Whyphysiciansare unpreparedtotreatpatientswhohavealcohol-anddrug-related disorders. AcadMed. 2001;76(5):410–8.

7.PolydorouS,GundersonEW,LevinFR.Trainingphysicians totreatsubstanceusedisorders. CurrPsychiatryRep. 2008;10(5):399–404.

8.AmericanCollegeofAcademicAddictionMedicine.Accredited AddictionMedicineFellowships.Availableat: https://www.acaam.org/ fellowship-training.AccessedApril25,2021.

9.TaylorEN,TimkoC,BinswangerIA,etal.Anationalsurveyofbarriers andfacilitatorstomedicationsforopioidusedisorderamonglegalinvolvedveteransintheVeteransHealthAdministration. SubstAbus. 2022;43(1):556–63.

10.KimHSandSamuelsEA.Overcomingbarrierstoprescribing buprenorphineintheemergencydepartment. JAMANetwOpen. 2020;3(5):e204996.

11.SubstanceAbuseandMentalHealthServicesAdministration. SubstanceUseDisorderTreatmentforPeoplewithCo-Occurring Disorders.2020.Availableat: https://store.samhsa.gov/sites/default/ ﬁles/SAMHSA_Digital_Download/PEP20-02-01-004_Final_508.pdf AccessedApril25,2021.

12.BurgessA,vanDiggeleC,RobertsC,etal.Team-basedlearning: design,facilitationandparticipation. BMCMedEduc. 2020;20(Suppl2):461.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

InitiationofBuprenorphineintheEmergencyDepartment: ASurveyofEmergencyClinicians

ArianaBarkley,MD*

LauraLander,MSW†

BrianDilcher,MD* MeghanTuscano,MPH†

*WestVirginiaUniversity,DepartmentofEmergencyMedicine, Morgantown,WestVirginia † WestVirginiaUniversity,DepartmentofBehavioralMedicineandPsychiatry, Morgantown,WestVirginia

SectionEditor:R.GentryWilkerson,MD

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedFebruary5,2024;AcceptedFebruary16,2024

ElectronicallypublishedJune27,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18029

Introduction: Initiationofbuprenorphineforopioidusedisorder(OUD)intheemergencydepartment (ED)issupportedbytheAmericanCollegeofEmergencyPhysiciansandisshowntobebeneﬁcial.This practice,however,islargelyunderutilized.

Methods: Toassessemergencyclinicians’ attitudesandreadinesstoinitiatebuprenorphineintheED weconductedacross-sectional,electronicsurveyofclinicians(attendings,residents,andnon-physician clinicians)inasingle,academicEDofatertiary-carehospital,whichservesaruralpopulation.Our surveyaimedtoassessemergencyclinicians’ attitudestowardandreadinesstoinitiatebuprenorphinein theEDandidentifyclinician-perceivedfacilitatorsandbarriers.Oursurveytookplaceaftertheinitiation oftheIMPACT(InitiationofMedication,PeerAccess,andConnectiontoTreatment)project.

Results: Ourresultsdemonstratedthelevelofagreementthatbuprenorphineprescribingiswithinthe emergencyclinician’sscopeofpracticewasinverselycorrelatedtoaverageyearsinpractice(R2 = 0.93). X-waiveredcliniciansindicatedfeelingmorepreparedtoadministerbuprenorphineintheEDR2 = 0.93. However,theywerenotmorelikelytoreportorderingbuprenorphineornaloxoneintheEDwithinthe priorthreemonths.Thosewhoreportedhavingafamilymemberorclosefriendwithsubstanceuse disorder(SUD)werenotmorelikelytoagreebuprenorphineinitiationiswithintheclinician’sscopeof practice(P = 0.91),norweretheymorelikelytoobtainanX-waiver(P = 0.58)orreportordering buprenorphineornaloxoneforpatientsintheEDwithinthepriorthreemonths(P = 0.65, P = 0.77). Cliniciansidentiﬁedavailabilityofpharmacists,inpatient/outpatientreferralresources,andsupportstaff (peerrecoverysupportspecialistsandcaremanagers)asprimaryfacilitatorstobuprenorphineinitiation. Inabilitytoensurefollow-up,lackofknowledgeofavailableresources,andinsufﬁcienteducation/ preparednesswereprimarybarrierstoEDbuprenorphineinitiation.Eighty-threepercentofclinicians indicatedtheywouldbeinterestedinadditionaleducationregardingOUDtreatment.

Conclusion: Ourdatasuggeststhatnewergenerationsofemergencycliniciansmayhaveless hesitancyinitiatingbuprenorphineintheED.Intime,thiscouldmeanincreasedaccesstotreatmentfor patientswithOUD.Understandingclinician-perceivedfacilitatorsandbarrierstobuprenorphineinitiation allowsforbetterresourceallocation.Clinicianswouldlikelyfurtherbeneﬁtfromadditionaleducation regardingmedicationsforopioidusedisorder(MOUD),availableresources,andfollow-upstatistics. [WestJEmergMed.2025;26(1.1)43–49.]

INTRODUCTION

Morethan564,000individualsdiedofopioidoverdosein theUSfrom1999–2020,1 accordingtotheUSCentersfor DiseaseControlandPrevention;morerecent,provisional datasuggeststhatannualoverdoseratescontinuedtorisein 2021.2 Aswouldbeexpected,withincreasedratesof overdose,emergencydepartment(ED)visitsforopioid overdosealsoincreasedin2020.3 Patientswithopioiduse disorder(OUD)arefrequentlyseenintheEDwithboth overdoseandotherlessemergentconditions.Patientsseenin theEDafteranon-fatalopioidoverdosehave >5%one-year mortalityrat.4 TheEDisalow-barrieraccesspointtothe healthcaresystem,andEDvisitsrepresentavaluable opportunitytoengagepatientswithOUDinpotentially lifesavingtreatment.

Buprenorphine,aUSFoodandDrugAdministration (FDA)-approvedmedicationforOUD(MOUD),hasbeen showntobeeffectiveindecreasingoverallopioiduse, reducingriskofopioidoverdose,andreducingbothopioidassociatedandall-causemortality.5 Buprenorphinehasbeen availabletoemergencycliniciansforthetreatmentofopioid withdrawalsince2002,andresearchhasshownthebeneﬁts ofbuprenorphineinitiationintheED.6 Speciﬁcally,in comparisontoreferraltotreatmentorbriefEDintervention, initiationofbuprenorphineintheEDresultsinincreased ratesofengagementinaddictiontreatmentat30daysand decreasedillicitopioiduse.7 TheAmericanCollegeof EmergencyPhysicians(ACEP)recommendstheinitiationof buprenorphineinappropriatepatients.Additionally,the ACEPconsensusstates: “Detectingandofferingevidencedbasedtreatmentsforpatientswithopioidusedisorderis alignedwiththegoalsofemergencymedicinetointerveneon high-mortalitydiseaseprocesses.”8

Unfortunately,MOUDsincludingbuprenorphineare largelyunderutilized,andthemajorityofpeoplewithOUD donotreceivedtreatmentwithMOUDs.9 Substanceuse disorders(SUD)areoneofthemosthighlystigmatized medicalconditionsintheworldamongcliniciansandthe generalpublic.10,11 Astudylookingatemergencyphysicians’ attitudestowardpatientswithSUDfoundthatemergency physicianshadalowerregardforpatientswithSUDthan othermedicalconditionswithbehavioralcomponents.12 The MOUDs,includingbuprenorphine,arealsostigmatized, whichimpactstreatmentaccessandprescribingpracticesfor thesemedications.13 Previous ﬁndingsidentifythemost signiﬁcantbarrierstoprescribingbuprenorphineintheED includelogisticalorsystemicfactorsaswellasperceived patientfactors(ie,socialbarriersandlackofinterestin treatment).14 Clinicianlackofknowledge,aswellastheir attitudesandbiases,canimpactwillingnesstoprescribe medicationssuchasbuprenorphineforpatientswithOUD, despiteMOUDbeingawellstudiedandeffective treatment.6,15 NotonlyarepatientsonMOUDstigmatized

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

InitiationofbuprenorphineintheEmergency Department(ED)foropioidusedisorder (OUD)hasbeenshowntobebene ﬁ cial,butis largelyunderutilized.

Whatwastheresearchquestion?

Whatareclinicians ’ attitudestoward initiatingbuprenorphineintheED,andwhat arethebarrierstoprescribing?

Whatwasthemajor ﬁndingofthestudy?

Clinicianlikelihoodofinitiatingtreatmentin theEDwasinverselycorrelatedtoyearsin practice.Theprimarybarriertoinitiating buprenorphinewasinabilityto ensurefollow-up.

Howdoesthisimprovepopulationhealth?

Eliminatingbarriersandimprovingclinician readinesstoinitiatebuprenorphineintheED couldincreaseaccesstocareforpatients withOUD.

buttheprescriberswhoprovidethemwithmedicationsare alsostigmatized.16

Topromoteengagementinandreferraltotreatmentfor OUD,ouracademicEDinitiatedtheIMPACTproject (InitiationofMedication,PeerAccess,Connectionto Treatment)in2020.KeyelementsoftheIMPACTproject includedelectronichealthrecord(EHR)promptsandorder sets,peerrecoverysupportspecialistsintheED,and availabilityofinpatientandoutpatientreferral,allofwhich arebarriersidentiﬁedinpreviousstudies.15,17–18 Additionally,whentheIMPACTprojectwasintroducedto theED,clinicianswereoffereda ﬁnancialincentivetoobtain aUSDrugEnforcementAdministrationX-waiver.The primarygoalofourstudywastoassessemergencyclinicians’ attitudestowardandreadinesstoinitiatebuprenorphinein theED,aswellasidentifyperceivedfacilitatorsandbarriers toinitiatingbuprenorphinetreatmentinanacademicED, afterimplementationoftheIMPACTprojectandits associatedresources.

METHODS

ThisstudywaspartofaStateOpioidResponse ImplementationprojectcalledIMPACT.Theprimary objectiveoftheprojectwastointegratepeerrecovery

supportspecialists(PRSS)intheED,toincrease buprenorphineprescribingforpatientswithOUD,andto increaseengagementandreferralstotreatmentforall patientswithSUD.WeextracteddatafromtheEHR regardingpatientdemographics,PRSSinteractionwith patients,andprescribingpracticesoveratwo-yearperiod fromMarch2020–March2022.Amixed-methodsmodelwas usedtoevaluatethedata.Thisprojectwasapprovedbythe institutionalreviewboard.

Weconductedacross-sectionalelectronic-basedsurvey regardingbuprenorphineprescribingintheEDwithall potentialEDprescribersincludingattendingphysicians, residentphysicians,physicianassistants,andnurse practitioners.Wedevelopedthesurvey,adaptingfrom previouslypublishedresearch.15,17–18 Priorsurveyshadbeen conductedinlargeurbanareasbuthadnotbeendeployedin amoreruralsetting.Oursurveywasdesignedtoidentify prescribers’ attitudestowardandreadinesstoinitiate buprenorphineintheEDandidentifyperceivedfacilitators andbarrierstoinitiatingbuprenorphinetreatmentinan academicEDofalarge,tertiary-carehospital,whichservesa ruralpopulation.Cliniciansweremadeawareofthestudy throughaninitialemail,twoemailreminders,aone-time announcementatourweeklydidacticconference,and ﬂyers postedthroughouttheED.Participantswereincentivized,as the ﬁrst100participantsreceiveda$10giftcard,andall participantswereenteredforachancetowina$100giftcard.

Thesurveycompletedbyemergencycliniciansincluded10 questionsfocusingonyearsinpractice,X-waiverstatus, prescribingpracticesintheEDinthepriorthreemonths, comfortwithtreatmentofOUDandprescribing buprenorphineintheED,andpersonalexperiencewith SUD.TwoadditionalLikert-scalequestionsassessedfor barriersandfacilitatorstoprescribingbuprenorphine.(See AppendixA forfullsurvey).Thesurveywaspublished March23,2022,andclosedMay15,2022.Surveyresponses wererecordedviaQualtrics(Qualtrics,Provo,UT),andthe datawasexportedtoasecureExcel ﬁle(MicrosoftCorp, Redmond,WA)foranalysis.Wethenorganizedand analyzedthedatausingSAS9.4(SASInstituteInc,Cary, NC)withchi-squaredorFisherexacttests.Wede-identiﬁed andextractedadditionaloperationalpatientdataonthe IMPACTprogramonarollingbasisfromtheEHR.

RESULTS

Atotalof95surveysweredistributedtoallemergency clinicians(attendingphysicians,residents,physician assistants,andnursepractitioners)Therewereatotalof43 respondentsandaresponserateof45%(16/50attendings, 21/30residents,6/15physicianassistantsandnurse practitioners).Threesurveyswerepartiallycompleted.We includedtwothathad >50%ofthequestionsansweredand excludedonesurveywithonlytwoquestionscompletedas thelatterrespondent’sintenttocompletewasinterpretedas

questionable.Ofthosewhoresponded,theiryearsinpractice rangedfrom1-50withanaverageof7.3years.Ofthe43 respondents,31indicatedtheywerefamiliarwiththe IMPACTprojectand12saidtheywerenot.Allthe respondentswhoindicatedtheywerenotfamiliarwiththe IMPACTprojectwereEDresidents.(See Tabl.)Notably, 83%ofallrespondentsindicatedtheywouldbeinterestedin additionaleducationrelatedtomedicationandresourcesfor OUDtreatment.

A ﬁve-pointLikertscalewasusedtoassessrespondents’ levelofagreementthatprescribingbuprenorphinewaswithin theirscopeofpractice.While78.6%ofrespondentsagreed thatprescribingbuprenorphinewaswithintheirscope,the levelofagreementwasfoundtobeinverselycorrelatedwith averageyearsinpractice(R2 = 0.93162)(Figure1).Regarding X-waiverstatus,16individualsidentiﬁedashavingtheir X-waiverand26indicatedtheywerenotX-waivered.When askedwhytheywerenotwaivered,fourindividualsindicated theywere “notinterested,” threesaidcostwasabarrier,seven saidtimewasabarrier,and12responded “other.” Inthe “other” category,tworespondedtheywereunsurehowto obtainthewaiver;twoquestionedwhetheritwasneeded;one said “intheprocess”;threesaid “justhaven’tdoneit” ;one indicatedtheyhadcompletedthetrainingbutwerenotyet licensed;andonesaid “Iknowthedatashowsitworks,butI

Table. Datasummaryofemergencyclinicianswhoparticipatedina surveyregardingED-initiatedbuprenorphine.

CountPercentage

Figure1. Agreementthatbuprenorphineiswithintheemergency clinician’sscopeofpracticeasassessedona5-pointLikertscalein comparisontoaverageyearsinpractice.

stillfeellikeadrugdealer.” Wefoundthatthosewhohadan X-waiver,incomparisontothosewhodidnot,weremore likelytofeelpreparedtoadministerbuprenorphineinthe ED(P = 0.02).

Toenableustodescribeprescribingpractices,prescribers werealsoaskedwhethertheyhadorderednaloxonefor patientsintheEDinthepriorthreemonths;29said “ yes ” and13said “ no. ” Whenaskedwhethertheyhadordered buprenorphineforpatientsintheEDinthepriorthree months,18said “ yes ” and24said “ no. ” Wealsoobserved thatthosewhohadanX-waiverwerenotmorelikely tohavereportedorderingbuprenorphineornaloxone forpatientsintheEDwithinthepriorthreemonths (P = 0.17),(P = 0.51).

Sixty-sevenpercentofcliniciansagreedthattheyfelt preparedtoadministerbuprenorphineintheED,53.7% agreedthattheyfeltpreparedtoprescribebuprenorphineas abridgetooutpatienttreatment,and47.6%agreedthatthey feltpreparedtoprescribebuprenorphineforhomeinduction. Sixty-twopercentofallrespondentsagreedthattheyhadall

theresourcesneededtoinitiatebuprenorphineintheED. Barriersandfacilitatorstoinitiatingbuprenorphineinthe EDareidentiﬁedin Figure2 and Figure3,respectively. Toassesspossiblepersonalbarriersandfacilitatorsof buprenorphineprescribingthefollowingwasasked: “Have youhad,ordoyoucurrentlyhaveafamilymemberorclose friendwithSUD?” Responsesindicated43%said “ yes ” and 57%said “ no. ” Thosewhoreportedhavingafamilymember orclosefriendwithSUDwerenotmorelikelyto1)agreethat buprenorphineinitiationiswithintheemergencyclinician’ s scopeofpractice(P = 0.91);2)obtainanX-waiver (P = 0.58);or3)reportorderingbuprenorphineornaloxone forpatientsintheEDwithinthepriorthree months(P = 0.65),(P = 0.77).

IMPACTProjectQualitativeResults

Overthetwo-yearperiod,1,205patientswereseeninthe EDbyPRSSs,13%ofwhomwerediagnosedwithOUDor opioidwithdrawal.Atotalof377werereferredfor buprenorphinetreatmentbythePRSSswithintheED;168of thosepatientsreceivedbuprenorphinetreatment,and42 weregivenatake-homeprescription.Atthestartofthestudy therewerethreeX-waiveredphysicians;duringthecourseof theproject,12additionalcliniciansobtainedtheirX-waiver, foratotalof15.

DISCUSSION

Oursurveyaimedtoevaluateemergencyclinicians’ attitudestowardandpreparednesstoinitiatebuprenorphine intheEDaswellasidentifyperceivedfacilitatorsand barrierstoinitiatingbuprenorphinetreatmentafterthe implementationoftheIMPACTprojectanditsassociated resources.Ourresultsshowedthat78.6%ofcliniciansagreed thatprescribingbuprenorphineintheEDwaswithintheir scopeofpractice.Asshownin Figure1,thelevelof agreementthatbuprenorphineiswithintheemergency

Knowledge of available resources

Ability to ensure follow up

Concerned about misuse / diversion

Concerned about safety

Lack of pa ent interest in MOUD

Provides minimal beneﬁt to pa ents

Concerned prescribing buprenorphine is not in my scope of prac ce

Figure2. Clinician-perceivedbarrierstoinitiatingbuprenorphineintheemergencydepartment.Identiﬁedbarriersweregradedwitha3-point Likertscale:somewhatabarrier,moderatebarrier,signiﬁcantbarrier. MOUD,medicationforopioidusedisorder.

Pharmacist in the ED

inpa ent referral resources

Outpa ent referral resources

EHR alert re naloxone

EHR alert re buprenorphine

Availablility of PRSS / CM

Figure3. Clinician-perceivedfacilitatorstoinitiatingbuprenorphineintheemergencydepartment.Identi ﬁedfacilitatorsweregradedwitha 3-pointLikertscale:somewhatafacilitator,moderatefacilitator,signiﬁcantfacilitator. ED,emergencydepartment; EHR,electronichealthrecord; PRSS,peerrecoverysupportspecialist; CM,casemanager.

clinician’sscopeofpracticewasinverselycorrelatedtoyears inpractice.Anotherstudyfoundthatclinicianswithfewer yearsinpracticeweremorelikelytobelievethatOUDislike otherchronicdiseasesandweremorelikelytoapproveof ED-initiatedbuprenorphine.18 Otherstudieshaveidentiﬁed emergencymedicineresidentsasenthusiasticandeagerto incorporatecareforOUDintotheirpractice.17,19 Webelieve theseresultsareencouraginganddemonstratethatnewer generationsofcliniciansmayhavelesshesitancytoward initiatingMOUDtreatmentintheEDsetting.Thischange will,intime,likelyincreaseaccesstocareforthose withOUD.

Sixty-sevenpercentofallcliniciansagreedthattheyfelt preparedtoadministerbuprenorphineintheED.Wesuspect clinicians’ levelofpreparednesscouldbeimprovedwith continuingeducationlecturesandfeedback.Notably,the majorityofrespondentsreportedtheywouldbeinterestedin additionaleducationrelatedtomedicationandresourcesfor OUDtreatment.

WefoundthatthosewithanX-waiver,incomparisonto thosewhodidnothaveanX-waiver,weremorelikelytofeel preparedtoadministerbuprenorphineintheED.Other studieshavefoundthatX-waiveredcliniciansreported higherlevelsofreadinessorpreparednesstoinitiate buprenorphineintheEDincomparisontothosewhowere notX-waivered.14,17 Previously,aneight-hourtraining coursewasrequiredtoobtainanX-waiver;thistraining requirement,andthehassleofobtainingawaiver,was previouslyidentifiedasabarriertoinitiatingbuprenorphine intheED.14,17–18,20 However, findingthatX-waivered cliniciansfeltmorepreparedtoadministerbuprenorphinein theEDmayreflectthevaluethatwasassociatedwiththe previouslyrequirededucationcourse.Notably,wealso foundthatthosewhohadanX-waiverwerenotmorelikely tohavereportedorderingbuprenorphineornaloxonefor patientsintheEDwithinthepriorthreemonths.This finding

potentiallysupportstheideathatsimplyincreasingthe numberofX-waiveredcliniciansdoesnotsigniﬁcantly improveaccesstocareifX-waiveredcliniciansarenot activelyprescribingMOUDs.21,22 Notably,ourdatawas collectedpriortotherecenteliminationofthenational X-waiverrequirement.

Whenweaskedwhetherhavinghadafriendorfamily memberwithSUDwouldaffectclinicians’ attitudestoward buprenorphineintheED,wefoundthat42.8%ofclinicians reportedhavinghadafamilymemberorclosefriendwith SUD.Thispersonalrelationship,however,didnotmake cliniciansstatisticallymorelikelyto1)agreethatprescribing buprenorphinewaswithintheemergencyclinician’sscopeof practice;2)obtainanX-waiver;or3)reportordering buprenorphineornaloxoneforpatientsintheEDwithinthe priorthreemonths.Toourknowledge,aprescriber’ s personalrelationshipstoindividualswithSUDhasnotbeen evaluatedinpriorstudies.

Sixty-twopercentofcliniciansindicatedtheyhavethe resourcestheyneedtoinitiatebuprenorphineintheED. WiththeIMPACTproject,asdescribedabove,clinicians haveresourcessuchaspeerrecoverysupportspecialistsinthe ED,EHRprompts,andcloseoutpatientfollow-upavailable. Additionally,ouracademicEDisstaffedwithpharmacists andcasemanagers/socialworkers24/7.Giventhenumberof resourcesavailable,wewouldhaveexpectedthatmore clinicianswouldhavefelttheyhavetheresourcesnecessary toinitiatebuprenorphineintheED.Wesuspectitispossible thatmanycliniciansfelttheydidnothavetheresources necessarybecausetheyweresimplyunawareoftheavailable resources.Notably,lessthan75%ofrespondentswere familiarwiththeIMPACTproject.Allofthosewhowere unfamiliarwiththeIMPACTprojectwereresidents;this highlightsanopportunityforadditionaleducation.

Anumberofstudieshavebeenconductedlookingat facilitatorsandbarrierstobuprenorphineinitiationinthe

ED.14,17–18

Previouslyidentiﬁedbarrierstoinitiating buprenorphineintheEDincludethefollowing:lackof training/experience;concernsregardingmisuse/diversion/ harm;patientinterest;time/competingprioritiesintheED; concernsregardingfollow-up;concernsregardingincreased EDvolume;andfeelingasifprescribingbuprenorphinewas notwithintheirscopeofpractice.14,17–18

Notably,withtheimplementationoftheIMPACTproject anditsassociatedresources,severalsystemic/logistical barriershavebeeneliminatedasPRSSsareavailableinthe ED,outpatientfollow-upcanbeensured,andtheEHRis equippedwithpromptsandordersetsregardingboth buprenorphineandoutpatientreferrals.

Ourcliniciansidentifiedinabilitytoensurefollow-up, limitedknowledgeofavailableresources,andlackof education/preparednessasthetopthreebarrierstoinitiating buprenorphineintheED.AlthoughtheCOAT (comprehensiveopioidaddictiontreatment)clinichasa standingappointmentforEDreferrals,andPRSSsworkto facilitatetheseappointments,andevenaccompany patientstotheseappointments,concernregardingfollow-up wasstilltheprimarybarrieridentifiedbyclinicians. Arecentstudyvalidatedtheseconcernsasitfoundthat lessthan30%ofpatientswho fillbuprenorphine prescriptionsfromtheED fillsubsequentbuprenorphine prescriptions.23 Currentlywedonothavedataregarding EDfollow-upratesorratesofsubsequentbuprenorphine refills;however,thisisanareaofinterestforfuture investigationtobetterevaluatetheeffectivenessofour IMPACTprogram.

Previouslyidentifiedfacilitatorstobuprenorphine initiationintheEDincludeabilitytoensurefollow-up; supportstaff – PRSSs/socialwork/caremanagers;department protocols;EHRordersets;pharmacistconsultation;and feedbackonpatientexperiences.14,17–18 Ourclinicians identifiedavailabilityofpharmacistsandofbothinpatientand outpatientresources,andthepresenceofPRSSsand caremanagersasprimaryfacilitatorstobuprenorphine initiationintheED.Thefactthatcliniciansidentified pharmacistavailabilityasasignificantfacilitatorlikely highlightsunderlyingcliniciandiscomfortwiththe pharmacologyofbuprenorphineandagainhighlightsan opportunityforongoingeducationandexperience.Notably, timewasnotaprimarybarrieridentifiedbyourclinicians,and thismaybeduetothepresenceofadditionalsupport staffintheED.

LIMITATIONS

Ourstudyhasseverallimitations.Overallwehadasmall samplesize,andourrespondentsallworkatthesame academiccenter.Additionally,nearlyhalfofrespondents wereresidentswithfewerthanthreeyearsinclinicalpractice. Ourdatawascollectedpriortotheeliminationofthe X-waiverrequirement.Itispossiblethatthisnewlegislation

hassinceinﬂuencedprescribers’ attitudestoward buprenorphineaswellasprescribingpractices.Results relatedtofacilitatorsandbarriersmaynotbegeneralizable tocommunity-based,non-academicEDsthatdonothave similarresources.Additionally,ourresultsmaynotbe generalizabletoacademicEDsinurbanareas.

CONCLUSION

Theresultsofoursurveyidentifiedthefollowing: 1)agreementthatbuprenorphineiswithintheemergency clinician’sscopeofpracticewasinverselycorrelatedtoyears inpractice;2) >80%ofclinicianswereinterestedin additionaleducationregardingMOUDsandresourcesfor OUDtreatment;3)thosewithanX-waiverweremorelikely toreportfeelingmorepreparedtoadministerbuprenorphine intheEDincomparisontothosewhowerenotX-waivered; and4)clinicianswhoreportedhavinghadafamilymember orclosefriendwithSUDwerenotmorelikelytoagreethat buprenorphineinitiationiswithintheemergencyclinician’ s scopeofpractice,norweretheymorelikelytoobtainan X-waiverorreportorderingbuprenorphineornaloxonefor patientsintheEDwithinthepriorthreemonths.Wealso identifiedclinician-perceivedbarriersandfacilitatorsto initiatingbuprenorphineintheED.Ourcliniciansidentified inabilitytoensurefollow-upasaprimarybarriertoinitiating buprenorphineintheED.

Moreresearchisneededonretentionintreatmentfollowing EDreferraltoidentifywhatfactorsareassociatedwith successfultransitionsofcarefromED-initiatedMOUDto community-basedtreatment.Education/preparednesswas alsoidentifiedasasignificantbarrier.Weplantoaddressthis withadditionaldidacticsandprogramupdates.Timewasless ofabarrier,likelysecondarytotheavailabilityofpharmacists, supportstaff,andinpatientandoutpatientresources, whichwereidentifiedasfacilitators.Abetterunderstandingof facilitatorsandbarriersallowsforbetterresourceallocation.

ACKNOWLEDGMENTS

Ourresearchwassupportedbyagrant(G230766)from theSubstanceAbuseandMentalHealthServices AdministrationthroughasubcontractfromtheWest VirginiaDepartmentofHealthandHumanResources BureauforBehavioralHealth.

AddressforCorrespondence:LauraLander,MSW,WestVirginia University,DepartmentofBehavioralMedicineandPsychiatry,930 ChestnutRidgeRd.,Morgantown,WV26505.Email: llander@hsc. wvu.edu

ServicesAdministrationthroughasubcontractfromtheWest VirginiaDepartmentofHealthandHumanResourcesBureaufor BehavioralHealth.Therearenootherconﬂictsofinterestorsources offundingtodeclare.

REFERENCES

1.USCentersforDiseaseControlandPrevention.Opioiddataanalysis andresources.2022.Availableat: https://www.cdc.gov/opioids/data/ analysis-resources.html#anchor_data_sources AccessedSeptember19,2022.

2.USCentersforDiseaseControlandPrevention.Drugoverdosedeaths intheU.S.top100,000annually.2021.Availableat: https://www.cdc. gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm AccessedSeptember19,2022.

3.SoaresWE,MelnickER,NathB,etal.Emergencydepartmentvisitsfor nonfatalopioidoverdoseduringtheCOVID-19pandemicacrosssixUS HealthCareSystems. AnnEmergMed. 2022;79(2):158–67.

4.WeinerSG,BakerO,BernsonD,etal.One-yearmortalityofpatients afteremergencydepartmenttreatmentfornonfatalopioidoverdose. AnnEmergMed. 2020;75(1):13–7.

5.LarochelleMR,BernsonD,LandT,etal.Medicationforopioiduse disorderafternonfatalopioidoverdoseandassociationwithmortality:a cohortstudy. AnnInternMed. 2018;169(3):137–45.

6.NationalInstitutesofHealth.Initiatingbuprenorphinetreatmentinthe emergencydepartment.2022.Availableat: https://nida.nih.gov/ nidamed-medical-health-professionals/discipline-speciﬁc-resources/ emergency-physicians-ﬁrst-responders/initiating-buprenorphinetreatment-in-emergency-department.AccessedSeptember19,2022.

7.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence:a randomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

8.HawkK,HoppeJ,KetchamE,etal.Consensusrecommendationson thetreatmentofopioidusedisorderintheemergencydepartment. Ann EmergMed. 2021;78(3):434–42.

9.U.S.DepartmentofHealthandHumanServices.Keysubstanceuse andmentalhealthindicatorsintheUnitedStates:R=resultsfromthe 2019nationalsurveyondruguseandhealth.2020.Availableat: https:// www.samhsa.gov/data/sites/default/ﬁles/reports/rpt29393/ 2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm AccessedSeptember19,2022.

10.vanBoekelLC,BrouwersEPM,vanWeeghelJ,etal.Stigmaamong healthprofessionalstowardpatientswithsubstanceusedisordersand

itsconsequencesforhealthcaredelivery:systematicreview. Drug AlcoholDepend. 2013;131(1–2):23–35.

11.RoomR.Stigma,socialinequalityandalcoholanddruguse. Drug AlcoholRev. 2005;24(2):143–55.

12.MendiolaCK,GalettoG,FingerhoodM.Anexplorationofemergency physicians’ attitudestowardpatientswithsubstanceusedisorder. J AddictMed. 2018;12(2):132–5.

13.BozinoffN,AndersonBJ,BaileyGL,etal.Correlatesofstigmaseverity amongpersonsseekingopioiddetoxiﬁcation. JAddictMed. 2018;12(1):19–23.

14.LowensteinM,KilaruA,PerroneJ,etal.Barriersandfacilitatorsfor emergencydepartmentinitiationofbuprenorphine:aphysiciansurvey. AmJEmergMed. 2019;37(9):1787–90.

15.MoranGE,SnyderCM,NoftsingerRF,etal.(2017). Implementing Medication-assistedTreatmentforOpioidUseDisorderinRuralPrimary Care:EnvironmentalScan.Rockville,MD:AgencyforHealthcare ResearchandQuality;2017.

16.Dickson-GomezJ,SpectorA,WeeksM,etal. “You’renotsupposedto beonitforever”:medicationstotreatopioidusedisorder(MOUD) relatedstigmaamongdrugtreatmentcliniciansandpeoplewhouse opioids. SubstAbuse. 2022;16:117822182211038.

17.HawkKF,D’OnofrioG,ChawarskiMC,etal.Barriersandfacilitatorsto clinicianreadinesstoprovideemergencydepartment-initiated buprenorphine. JAMANetworkOpen. 2020;3(5):e204561.

18.ImDD,CharyA,CondellaAL,etal.Emergencydepartmentclinicians’ attitudestowardopioidusedisorderandemergencydepartmentinitiatedbuprenorphinetreatment:amixed-methodsstudy. WestJ EmergMed. 2020;21(2):261–71.

19.WhitesideLK,D’OnofrioG,FiellinDA,etal.Modelsforimplementing emergencydepartment–initiatedbuprenorphinewithreferralfor ongoingmedicationtreatmentatemergencydepartmentdischargein diverseacademiccenters. AnnEmergMed. 2022;80(5):410–9.

20.MartinA,KunzlerN,NakagawaJ,etal.Getwaivered:aresident-driven campaigntoaddresstheopioidoverdosecrisis. AnnEmergMed. 2019;74(5):691–6.

21.DuncanA,AndermanJ,DeseranT,etal.Monthlypatientvolumesof buprenorphine-waiveredcliniciansintheUS. JAMANetwOpen. 2020;3(8):e2014045.

22.GordonAJ,KennyM,DunganM,etal.AreX-waivertrainingsenough? Facilitatorsandbarrierstobuprenorphineprescribingafterx-waiver trainings. AmJAddict. 2022;31(2):152–8.

23.SteinBD,SalonerB,KerberR,etal.Subsequentbuprenorphine treatmentfollowingemergencyphysicianbuprenorphineprescription ﬁlls:anationalassessment2019to2020. AnnEmergMed. 2022;79(5):441–50.

ORIGINAL RESEARCH

ANovelUseofthe “3-DayRule”:Post-dischargeMethadone DosingintheEmergencyDepartment

JennaK.Nikolaides,MD,MA*†

TranH.Tran,PharmD*‡

ElisabethRamsey,LCSW*

SophiaSalib,MSW,MPH*

HenrySwoboda,MD§

*RushUniversityMedicalCenter,SubstanceUseInterventionTeam, DepartmentofPsychiatryandBehavioralSciences,Chicago,Illinois

† RushUniversityMedicalCenter,DepartmentofEmergencyMedicine, Chicago,Illinois

‡ ChicagoCollegeofPharmacy,MidwesternUniversity,DownersGrove,Illinois § Queen’sUniversity,DepartmentofEmergencyMedicineandAddictions Medicine,Kingston,Canada

SectionEditor:PierreBorczuk,MD

Submissionhistory:SubmittedMarch31,2023;RevisionreceivedFebruary9,2024;AcceptedFebruary16,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18030

Introduction: Methadoneisamedicallynecessaryandlifesavingmedicationformanypatients withopioidusedisorder.Toadequatelyaddressthesepatients ’ needs,methadoneshouldbeoffered inthehospital,butbarriersexistthatlimititscontinuationupondischarge.Thecodeoffederal regulationsallowsformethadonedosingasaninpatientaswellasoutpatientdispensingfor uptothreedaystofacilitatelinkagetotreatment.Asaqualityinitiative,wecreatedanewwork ﬂ ow fordischargingpatientsonmethadonetoreturntotheemergencydepartment(ED)for uninterrupteddosing.

Methods: Ouraddictionmedicineteamchangedhospitalmethadonepolicytobetterallow hospitalizationasawindowofopportunitytostartmethadone.Thisnecessitatedthecreationofawarmhandoffprocesstolinkpatientstomethadoneclinicsifthatlinkagecouldnothappenimmediatelyon discharge.Thus,ourteamcreatedthe “EDBridge” process,whichusesthe “3-dayrule” todispense methadonefromtheEDposthospitaldischarge.Wethenfollowedeverypatientwedirectedthroughthis workﬂowasanobservationalcohortforoutcomesandtrends.

Results: OfthepatientsforwhomEDbridgedosingwasplanned,40.4%completedallbridgedosing andanadditional17.3%receivedatleastonebutnotallbridgedoses.Establishedmethadonepatients madeup38.1%ofsuccessfullinkages,and61.9%werepatientswhowerenewlystartedonmethadone inthehospital.

Conclusion: Improvingmethadoneasatreatmentoptionremainsanongoingissueforpolicymakers andadvocates.OurEDbridgeworkﬂowallowsustoexpandaccessandcontinuationofmethadonenow usingexistinglawsandregulations,andtobetterusehospitalsasapointofentryintomethadone treatment.[WestJEmergMed.2025;26(1.1)50–55.]

INTRODUCTION

Therearemanyregulatorybarrierstoinitiating medicationsforopioidusedisorder(MOUD)intraditional healthcaresettings.Sincetreatmentwithmethadone,an opioidagonist,orwithbuprenorphine,apartialopioid agonist,remainsthestandardofcareforpatientswithopioid

usedisorder(OUD),therehasbeenmuchfocusrecentlyon easingorcircumnavigatingbarrierstofacilitatelinkageto treatment.Whilethepassageofthe2023Consolidated AppropriationsActremovedtheX-waiverrequirementfor buprenorphineprescribing,1 methadonedispensingremains restrictedtoopioidtreatmentprograms(OTP).Giventhese

restrictionsonprescribingandotherlegalconsiderations, manyhospitalsareoftenhesitanttostartandtitrate methadoneforinpatientswithOUD.

Everyyeardrug-relateddeathscontinuetoincrease,and in2021over80,000peoplediedofanopioidoverdose.2 UnderuseofMOUDiscommonamongpatientsseeninthe hospitaldespiteevidencesupportingemergencydepartment (ED)andinpatientinitiationasbeneficialopportunitiesto starttreatment.3,4 Toaddressthisdeficit,ourtertiarymedical centercreatedtheSubstanceUseInterventionTeam(SUIT) in2018.5 TheSUITiscomprisedofemergencyphysicians whoaredual-ortriple-boardedinmedicaltoxicologyand/or addictionmedicine,psychiatricnursepractitioners,social workers,arecoverysupportspecialist,andapharmacist; SUITisavailableduringbusinesshours,Mondaythrough Friday.Theteamisacomprehensiveaddictionmedicine consultservice,workingtowardincreasingtherecognition, treatment,andlinkagetooutpatientcareforallsubstance usedisorders.TheSUIToffersallformsofMOUD, includingbuprenorphineandmethadone.Forpatientswho requestedorpreferredmethadone,thedosetitrationwas guidedbythe2019versionoftheCalifornia[CA]Bridge in-hospitalmethadonestartprotocol,6 tailoredtoeach patient,withthemostaggressivepossibletitrationbeing 40milligrams(mg)onday1,50mgonday2,and60mgon day3,atwhichpoint,thedosewasnotincreaseduntilevery fivedays.

Startingmorepatientsonmethadonenecessitatedthe craftingofnewpoliciesandproceduresatourcenterthat wouldallowawarmhandofftomethadoneOTPs.TheCode ofFederalRegulationsTitle21restrictsthedispensingof methadonetoOTPsandspeciﬁesthatmethadonemaybe administeredforthreedaysinahealthcaresettingforthe purposeofalleviatingwithdrawalwhilearrangementsare madetorefertotreatment.6 Itdoesnotlimittreatmentto threedays;however,ifthepatientisinthehospitalfor reasonsotherthanwithdrawal,MOUDcanbeused “to maintainordetoxifyapersonasanincidentaladjunctto medicalorsurgicaltreatmentofconditionsotherthan addiction.”7 Therefore,methadone,ifstartedwhilean inpatient,canbecontinuedfortheentiretyofthestay.Prior toSUIT’screation,ourtertiarymedicalhospitalhadan internalpolicythatifmethadonewasstartedforapatientnot previouslyenrolledinanOTP,thepatienthadtobeweaned priortodischargebecauseoftheprescribinglimitation. Becauseweaningwithoutfurthermaintenancetreatment onlyaddressesthephysicaldependenceintheshortterm whileneglectingthechronicdiseaseofOUD,itincreasesrisk ofrelapse,fataloverdose,andall-causemortality.8–11 This policy,althoughcompliantwiththelaw,wasnotevidencebasedbestpractice.

TheSUITcreatedanewpolicyandworkﬂowthatallowed thestartofaninpatienttitrationofmethadoneforpatients notpreviouslyenrolledinanOTP,arrangedlinkagetoOTPs

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

FederalregulationsallowEDstodispense methadoneforopioidusedisorder, andhospitalscanusethe3-dayruleto assistwithlinkagestomethadone maintenanceprograms.

Whatwastheresearchquestion?

WelookedatthefeasibilityofusingtheEDas apost-acutecarelandingsitetobridge patients ’ methadonetreatmentindischarging hospitalizedpatients.

Whatwasthemajor ﬁndingofthestudy?

Fortypercentofpatients(21/54)completed allbridgedosing,ofwhom62%werenewly initiatedonmethadoneinthehospital.

Howdoesthisimprovepopulationhealth?

Thiswork ﬂ owisanoveluseofthe3-dayrule toexpandaccesstomethadoneviatheED.

whilestillinpatient,andavoidedweaningpriortodischarge; ifpatientscouldnotimmediatelybetreatedatanOTPupon discharge(duetogapsintreatment,includingweekendor holidayclosures),theEDisusedasapost-dischargesetting forcontinueddosingunderthethree-dayruletocompletea warmhandoff.Thisworkﬂowwasreviewedbyourhospital’ s pharmacy,compliance,andlegaldepartments,allofwhich agreedthatitcompliedwithexistinglawsandhelpedusenact thechangeinhospitalpolicy.Oncethisprocesswasbuilt,our teamrealizedthatitwasalsohelpfulforthosepatientsin establishedOTPswhoweredischargedonweekendsor holidaysandcouldn’treturntotheirOTPfordosinguntilthe nextbusinessday.

HavingtheEDasapost-acutecarelandingsitefor methadonecontinuationhelpedavoiddisruptionof establishedMOUDaswellasnewlyinitiatedMOUD. Becausethenew-startmethadonetitrationwasmore aggressivethanatypicaloutpatientinitiationofmethadone, whenpatientsreturnedtotheED,thedoseadministeredwas theirdischargedoseandwasnottitratedintheEDtokeep thematsteady-stateandtoavoidaneedforobservationin theEDafterdosing.Duringthetimeframethisworkﬂowwas builtandused,theOTPsinourcityindependentlyunderwent changes.OneOTPinparticularagreedtohonorhospital titrationsonday1intheirclinicifthepatientbrought dischargepaperworkwiththem.Theprogrambecamea

preferredoptionforthisworkﬂow,althoughmanypatients eitheralreadyusedorrequestedotherOTPs.

Thisarticleservesasaproofofconceptandan observationalcohortofallpatientsthatSUITdirectedto returntotheEDformethadonedosing.

METHODS

Thesettingofthisstudywasourtertiaryurbanmedical center.Patientsidenti fi edasbeinginneedofan “ED bridge ” wereincludedinthisstudyiftheywereseenbythe SUITconsultservice;iftheywereidenti fi edaseither alreadyinamethadoneOTPornewlystartedon methadoneduringthehospitalizationandinneedof enrollmentinanOTP;andiftheprimaryteamdetermined thattheywouldbedischargedonadaywherethepatient wouldnotimmediatelybeabletogetoutpatientmethadone dosingbutwithaplaninplaceforlinkingtoanOTPwithin 72hoursofdischarge.Thisidenti fi cationusuallyhappened onaThursdayorFridayinanticipationofaweekend dischargeorfornewmethadonestartswhenanOTP appointmentcouldnotbemadeforthedayafterdischarge. SocialworkersontheSUITteammadeclearfollow-up plansbycontactingcooperatingOTPsaheadoftime. Patientswereexcludedfromthestudyiftheyendedupnot dischargingasplannedandtheEDbridgewasnolonger required,orifpatientsdeclinedtoreturn.Thesepatients weremanuallytrackedbychartreviewtodetermine whethertheyreturnedtotheEDfordosingovertheperiod fromJuly2019 –July2022.

The “EDbridge” processconsistedof1)instructingthe patienttoreturntotheEDeverydaystartingthemorning followingthedayofdischargeformethadoneadministration untilthedayofplannedOTPintakeorreturn(maximum threedays);2)writingacareplannoteinthechartnotifying theEDofthedosingplan,daysofdosing,andpolicy; 3)enteringanexpectedarrivalnotiﬁcationontheEDtrack board;and4)triagingthepatientonarrivaltoalow-acuity partoftheEDformethadonedosingandimmediate dischargeaslongastheydidnotappeartobeintoxicatedor haveanothercomplaint.

Atemplatednoteforthe “EDbridge” careplan (Appendix1)wasapprovedbythehospital’sPharmacyand TherapeuticsCommitteetoprovideconsistencyforthe process.Itincludedadotphraseforanotetemplatethatthe emergencycliniciancouldalsousewhenthepatientreturned. Theelectronichealthrecord(EHR)usedinourhospitalis Epic(EpicSystemsCorporation,VeronaWI).Ourhospital’ s methadonepolicywasamendedtoincludetheEDbridge pathwayandapprovedbyourhospital’scomplianceand legalofﬁces.Thepharmacydepartmentdisseminated hospital-widenotiﬁcationaboutthepolicyupdatesand providededucationaboutthenewprocesstoprescribers, pharmacists,nurses,andclinicalstaff.Thisstudyreceived institutionalreviewboardapproval.

Theprimaryoutcomemeasurementswerethepatient returnratetotheEDfordosingandthenumberofdoses completed.AnEDbridgewasconsideredsuccessfulifthe patientcamefordosingonallplanneddays;partially successfuliftheycamefordosingonsomeoftheplanned daysbutmisseddaysofdosing;andunsuccessfuliftheydid notcomeforanyoftheplanneddaysofdosing.Outcomes anddemographicdataareexpressedbydescriptivestatistics.

RESULTS

Therewere53plannedEDbridgessetupfor47unique patients.OneEDbridgewasexcludedafterthepatient stayedthroughtheweekendanddidn’trequireit.Several patientsusedtheEDbridgeworkﬂowmorethanoncedueto repeatedhospitalizations:threepatientsusedittwice,and onepatientuseditthreetimes.Demographiccharacteristics ofthe52plannedbridgesaresummarizedinthe Table. AllthepatientswithOUDwhousedthisworkﬂowwere usingheroin.

Ofthe52plannedEDbridges,21patientscompletedall necessarybridgedoses(40.4%).Ninepatients(17.3%) returnedtotheEDforatleastonedaybutdidn’tpresentfor allplanneddays.Theremainingplanswerenotsuccessful because22patients(42%)eitherdidnotreturntotheEDor lefttheEDbeforereceivingonedose.Intotal,94visitsfor methadonedosingintheEDwereplannedviatheEDbridge workﬂow,and40visitsactuallyoccurred.TheaverageED lengthofstay(LOS)fromtriagetodischargewas120 minutes,witharangeof36-682minutes.Sixofthe40visits requiredfullevaluationsforadditionalcomplaints. Excludingthesesixvisits,theaverageEDLOSwas89 minutes.Ofthe52plannedEDbridges,theaveragenumber ofdaysrequiredtocompletelinkagetotreatmentwas1.8 days.Forpatientswhosuccessfullycompletedallnecessary bridgedoses,theaveragenumberofdaysforlinkagewas 1.3days.

Patientswerelinkedtooneof10methadoneclinics,allof whichacceptedpatientswithMedicaid.Eightpatientswho werealreadyestablishedinamethadoneclinicaccountedfor 38.1%ofsuccessfullinkages.

DISCUSSION

Forthepurposesofthisstudy,apatientwasdeﬁnedasa “ new ” methadonepatientiftheywerenotenrolledinaclinic priortotheiradmissiontothehospitalandasan “established” patientiftheywere.Theterms “ new ” and “established” werenotdescriptorsofstabilityintreatment becauseoccasionallyevenestablishedpatientsneededtobe newlyrestartedonmethadoneduetomissingdosesattheir establishedOTP,andtheoutcomesofwhethertheycomplied withtheEDbridgeplanwereessentiallysimilarbetweenthe twogroups.Becauseourprojectlackedfollow-upwith patientsatalatertimepoint,wewereunabletodiscernthe reasonforpatientsnotreturningtotheED.

Table. Characteristicsofparticipantsintheemergencydepartmentbridgeprogramforpost-dischargemethadonedosing.

Characteristics(attimeofEDbridge)

Age

Average(years)44.647.945.140.5

Range(years)29 – 6929 – 6931 – 6129 – 64

Housingstatus

,emergencydepartment.

“Success” wasdeﬁnedasthepatientreturningforall planneddays.Theredidn’tappeartobeanydemographic factorthatcorrelatedwiththesuccessofthebridge,although thisstudywasnotpoweredtolookforanystatisticaltrends. Theclearestexplanationfromthedatawewereabletocollect isthatifabridgeplanwasshorter,itwasmorelikelytobe successful.Onaverage,patientsreturnedforapproximately oneday.Planslongerthanonedaywerelesslikelytobe successful.Nearlyhalfofthe10unsuccessfulbridgeplans occurredwithinarelativelyshortfour-monthtimespan (September–December2021).Emergencydepartmentwait timesandtheCOVID-19pandemicmayhavecontributedto thishighrateofunsuccessfulbridgedosesduringthattime.

PriortoinstitutingtheEDbridgeprocessinourcenter,we wouldroutinelyholdpatientscommittedtotreatmentinthe hospitaltoensurelinkagetoamethadoneclinicwithno misseddosestodecreasethepatients’ riskofrelapse,

overdose,anddeathupondischarge.TheEDbridgeprocess allowedgreater ﬂexibility:patientswhowerecommittedto treatmentbutwerereadyfordischargeotherwisecouldleave andcomebackfordosing;patientswhoweregettingplaced inpost-acutecaresettingsbutneededtotransportfor methadonecouldnowtransportbacktotheEDfordosing, therebyallowingweekenddischarges;andevenpatientswho wereleavingagainstmedicaladvicewereofferedthe opportunitytodoseintheEDtoreinforcethemessagethat MOUDisapriority.Whileitisdifﬁculttodeterminewhether everyEDbridgeplandecreasedLOS,thefactthat40visitsto ourEDformethadonedosingdidoccurviatheEDbridge processsuggeststhatwediddecreaseinpatienthospitaldays andthatthismitigatedtheincreaseduseofEDresourcesfor thesevisits.

InstitutingtheEDbridgeworkﬂowwasanadjustmentfor theEDstaff.Sincetherewasnopop-upintheEHR,the

triagenursesattimesneededtoberemindedtolookforan expectedarrivalnoteandtoberemindedthatthesepatients couldbetriagedtothelowacuitypartoftheED.Most clinicianswrotestandardEDnotesanddidnotusethepreformedtemplatednoteforamethadonevisit.Ittooksome timeforallstaffmemberstogetusedtothenewworkflow, whichlikelyexplainedtheaverageLOSbeingapproximately 1.5hourswhenafullevaluationwasnotrequired.TheLOS alsoaccountedfortimespentinthewaitingroomand cliniciansorderingmethadoneandprovidingdischarge instructions.Itwasnot1.5hoursofobservationafterthe dosewasgiven.Basedonourteam’sexperienceswith teachingtheworkflow,itappearedthattheEDstaffwas receptivetotheoverallidea,inpartbecauseourinstitution hadgottenusedtothecultureoftheemergencyphysician-led SUITteam.DuringtheCOVID-19pandemic,therewasalso turnoverintheEDnurseworkforcethatnecessitatedretrainingsontheworkflow,whichcouldhavealsocontributed tothewidevariationinLOS.

Thisstudytookplaceinalargeurbanenvironmentfrom 2019–2022,aperiodthatnotonlyencompassedtheCOVID19pandemicbutalsothecontinuedworseningoftheopioid epidemic.Duringthattime,thereweresignificantand evolvingchangestohowOTPsfunctionedduetoCOVID-19 emergencyconditionsandtothedesiretoreducebarriersto treatment.TheOTPschangedtheirintakeprocess, sometimesseveraltimesthroughoutthatperiod,at firsttobe morerestrictive12 andthenlatertoallow flexibility.Priorto thisperiod,atypicalOTPhadspecificdaysdesignatedfor intakeappointments.Intakescouldtakeapproximatelyone hour,andapatientmaynothaveactuallystarteddosing onthatday.Patientswereofteninstructedtoreturnafew dayslatertothenmeetwiththecliniciantostarttheir methadonetitration.

ThetypicalinitialdosingscheduleisdailydosingMonday throughSaturdaywithatake-homedosedispensedon SaturdayforuseonSundaywhentheOTPwasclosed. InitiallyourSUITprogramwasabletohelppatients completephoneintakeswhilehospitalized;however,this protocollaterevolvedtomatchthechangesinOTPs,which developedexpandeddaysforwalk-inintakes.SeveralOTPs alsochangedtheirworkflowsregardingdayofintakeand dayof firstdose,andsometimeswehadtouseourEDbridge protocoltokeepdosingpatientsduringthegapbetweenthe dayoftheirintakeandthedayoftheir firstdose.Duringthis period,OTPsalsopermittedmoretake-homemethadone doses,sometimesswitchingtoMonday-Wednesday-Friday dosingscheduleswitheveryotherdaytake-homedoses, weeklydosingscheduleswithsixdaysoftake-homedoses,or evenmonthlydosingwith27daysoftake-homedoses.This allowedpatientstonothavetogototheOTPasoften, facilitatingsocialdistancing,butitalsoledtogreateraccess todivertedmethadone.Thegoalofour “EDbridge” workflowwastodecreasedosedisruptionbyprovidingaway

forpatientstoobtainmethadonesafelywhilecomplyingwith dispensingrestrictions.Itispossiblepatientsobtained methadonethroughothermeansand,thus,didnotreturnfor theEDbridge.

OneOTPinoururbanareadecreasedthebarrierstoentry signiﬁcantlyoverthistimeperiod:theyexpandedintakesto MondaythroughFriday;alloweddosingevenbeforefull completionofintake;didnotrequirephotoIDaslongasthe patienthadidentifyingpaperwork(includinghospital dischargepapers);andacceptedallformsofgovernment insurance.ThisOTPendedupbecomingthedefaultoption thatwecouldrelyonwhensettingupourEDbridgeplans, eventhoughwestilldidusetheworkﬂowforlinkingtoother OTPsaswell.Inareasofthecountrywithmorelimitedand restrictiveaccesstomethadoneOTPs,ourthree-dayED bridgemodelmaynotbeasfeasible.

LIMITATIONS

Thisstudytookplaceinanurbanareawithfederaland statesupportforOTPs.WedidnotlookatpatientfollowthroughforOTPintakesorretentioninlong-termtreatment. AnotherlimitationisthatfeedbackfromEDstaffonthis newworkﬂowwasnotcollectedtofullyassessattitudes andbarriers.

CONCLUSION

Expandingaccesstomethadoneremainsanissuefor policymakersandadvocates.Ideassuchasmobileclinics, newguidelinessuggestinglimiteddispensing,andproposals toallowstandardcommercialpharmaciestodispense methadoneareallongoingconsiderations.13 OurEDbridge workﬂow,however,allowsustoexpandaccessand continuationofmethadoneusingexistinglawsand regulations,andtobetterusehospitalsasapointofentryinto methadonetreatment.

AddressforCorrespondence:JennaKNikolaides,MD,Rush UniversityMedicalCenter,SubstanceUseInterventionTeam, DepartmentofPsychiatryandBehavioralSciences,1611W Harrison,Suite106b,Chicago,IL60612.Email: Jenna_Nikolaides@ rush.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.TheSUITservicesweresupportedinpartbyacontracttoRushUniversityMedicalCenterfromtheIllinois DepartmentofHumanServices,DivisionofSubstanceUse PreventionandRecovery,aspartoftheIllinoisOpioid-State TargetedResponse(STR)Grant(TI-080231)andIllinoisState OpioidResponse(SOR)Grant(TI-081699)fromtheSubstance AbuseandMentalHealthservicesAdministration.Thecontentis solelytheresponsibilityoftheauthorsanddoesnotnecessarily

representtheofﬁcialviewsoftheNationalInstitutesofHealth, AgencyforHealthcareResearchandQuality,SubstanceAbuseand MentalHealthServicesAdministrationortheIllinoisDepartmentof HumanServices.Therearenootherconﬂictsofinterestorsources offundingtodeclare.

REFERENCES

1.SubstanceAbuseandMentalHealthServicesAdministration.Waiver elimination(MATAct).2023.Availableat: https://www.samhsa.gov/ medications-substance-use-disorders/removal-data-waiverrequirement.AccessedMarch30,2023.

2.AhmadFB,CisewskiJA,RossenLM,etal.Provisionaldrugoverdose deathcounts.2024.Availableat: https://www.cdc.gov/nchs/nvss/vsrr/ drug-overdose-data.htm.AccessedMarch30,2023.

3.RosenthalES,KarchmerAW,Theisen-ToupalJ,etal.Suboptimal addictioninterventionsforpatientshospitalizedwithinjectiondruguseassociatedinfectiveendocarditis. AmJMed. 2016;129(5):481–5.

4.D’OnofrioG,ChawarskiMC,O’ConnorPG,etal.Emergency department-initiatedbuprenorphineforopioiddependencewith continuationinprimarycare:outcomesduringandafterintervention. J GenInternMed. 2017;32(6):660–6.

5.TranTH,SwobodaH,PerticoneK,etal.Thesubstanceuseintervention team:ahospital-basedinterventionandoutpatientclinictoimprovecare forpatientswithsubstanceusedisorders. AmJHealthSystPharm. 2021;78(4):345–53.

6.CaliforniaBridgeProgram.Methadonehospitalquickstart.2019. Availableat: https://www.acep.org/siteassets/sites/acep/media/ equal-documents/ca-bridge protocol methadone-hospitalquick-start nov-2019.pdf.AccessedOctober12,2023.

7.DrugEnforcementAdministration,DepartmentofJustice.21CFR 1306.07:Administeringordispensingofnarcoticdrugs.Availableat: https://www.ecfr.gov/current/title-21/part-1306/section-1306.07 AccessedMarch23,2023.

8.BaileyGL,HermanDS,SteinMD.Perceivedrelapserisk anddesireformedicationassistedtreatmentamongpersons seekinginpatientopiatedetoxiﬁcation. JSubstAbuseTreat. 2013;45(3):302–5.

9.DavoliM,BargagliAM,PerucciCA,etal.Riskoffataloverdoseduring andafterspecialistdrugtreatment:theVEdeTTEstudy,anationalmultisiteprospectivecohortstudy. Addiction. 2007;102(12):1954–9.

10.CornishR,MacleodJ,StrangJ,etal.Riskofdeathduringandafter opiatesubstitutiontreatmentinprimarycare:prospectiveobservational studyinUKGeneralPracticeResearchDatabase. BMJ. 2010;341:c5475.

11.CousinsG,BolandF,CourtneyB,etal.Riskofmortalityonandoff methadonesubstitutiontreatmentinprimarycare:anationalcohort study. Addiction. 2016;111(1):73–82.

12.JoudreyPJ,AdamsZM,BachP,etal.Methadoneaccessforopioiduse disorderduringtheCOVID-19pandemicwithintheUnitedStatesand Canada. JAMANetwOpen. 2021;4(7):e2118223.

13.CongressionalResearchService.H.R.6279-OpioidTreatmentAccess Actof2022.Availableat: https://www.congress.gov/bill/117thcongress/house-bill/6279?s=1&r=64.AccessedMarch31,2023.

ORIGINAL RESEARCH

VariabilityinPracticeofBuprenorphineTreatmentbyEmergency DepartmentOperationalCharacteristics

GrantComstock,MD*

NataliaTruszczynski,PhD

†

SeanS.Michael,MD,MBA‡ JasonHoppe,DO

SectionEditor:R.GentryWilkerson,MD

*MedicalCollegeofWisconsin,DepartmentofEmergencyMedicine, DivisionofMedicalToxicology,Milwaukee,Wisconsin

† UniversityofColoradoSchoolofMedicine,Aurora,Colorado

‡ UniversityofColoradoSchoolofMedicine,DepartmentofEmergencyMedicine, Aurora,Colorado

§ UniversityofColoradoSchoolofMedicine,DepartmentofEmergencyMedicine, DivisionofMedicalToxicologyandPharmacology,Aurora,Colorado

Submissionhistory:SubmittedMarch30,2023;RevisionreceivedDecember27,2023;AcceptedFebruary28,2024

ElectronicallypublishedJune11,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.18019

Introduction: Wesoughttodescribeemergencydepartment(ED)buprenorphinetreatmentvariability amongEDswithvaryingoperationalcharacteristics.

Methods: Weperformedaretrospectivecohortstudyofadultpatientswithopioidusedisorder dischargedfrom12hospital-basedEDswithinalargehealthcaresystemasasecondarydataanalysisof aqualityimprovementstudy.Primaryoutcomeofinterestwasbuprenorphinetreatmentrate.We describedtreatmentratesbetweenEDs,categorizedbytertileofoperationalcharacteristicsincluding annualcensus,hospitalandintensivecareunit(ICU)admissionrates,EDlengthofstay(LOS),and boardingtime.SecondaryoutcomeswereEDLOSand30-dayreturnrates.

Results: Therewere7,469uniqueEDencountersforpatientswithopioidusedisorderbetween January2020–May2021,ofwhom759(10.2%)weretreatedwithbuprenorphine.Buprenorphine treatmentrateswerehigherinlargerEDsandthosewithhigherhospitalandICUadmissionrates. EmergencydepartmentLOSand30-dayEDreturnratedidnothaveconsistentassociationswith buprenorphinetreatment.

Conclusion: RatesoftreatmentwithEDbuprenorphinevaryaccordingtotheoperationalcharacteristics ofdepartment.Wedidnotobserveaconsistentnegativerelationshipbetweenbuprenorphinetreatment andoperationalmetrics,asmanyfeared.Additionalfundingandtargetedresourceallocationshouldbe prioritizedbydepartmentalleaderstoimproveaccesstothisevidence-basedandlife-saving intervention.[WestJEmergMed.2025;26(1.1)56–62.]

INTRODUCTION

Theopioidcrisisisaworseningpublichealthemergency, withover80,000opioid-involvedoverdosedeathsintheUS in2021,anditisunlikelytoabateintheabsenceofeffectively implementedharmreductionandtreatmentstrategies.1 Buprenorphineisaneffective,evidence-basedtreatment resultinginincreasedabstinencefromillicitopioiduseand decreasedopioid-relatedmortality.2,3 Emergency department(ED)buprenorphinetreatmentisanevidencebasedpracticeandhasbeenassociatedwithincreasedfollowupandreducedillicitdruguseandmedicalcosts.4,5Although buprenorphineprescribingfromEDshasincreasedinrecent years,prescribingstilllagsfarbehindtheapparentneed,with disparitiesbypayerstatus,race,andethnicity.6,7

Improvedimplementationreliesonidentiﬁcationand removalofbarriers,providingresourcesforpatientsand clinicians,anddispellingstigmaandmisperceptions.8 Emergencydepartmentoperationalconsiderations,

includingperceptionsofinsuf ﬁcienttimeandincreasedED returnvisits,arecommonlycitedasperceivedbarriersto implementation. 9 However,thereal-worldinterplay betweenEDbuprenorphineinitiationandEDoperationsis notwelldescribed.UnderstandingtheimpactofED buprenorphinetreatmentonEDclinicaloperational outcomescaninformdecisionsonresourceallocationfor EDbuprenorphineprogramdevelopment.Conversely, barrierstoimplementationlikelyvarydependingonthe baselineoperationalperformanceofthedepartment. Identi ﬁ cationofoperationalcharacteristicsofEDswith lowerbuprenorphinetreatmentrateswouldallowfor targetedinterventions.

WesoughttodescribetheknowledgegapregardingED buprenorphinetreatmentvariabilityandoperational barrierstoimplementationby1)quantifyingtreatment ratesbetweenhospitalEDswithdifferentbaseline operationalcharacteristics,and2)measuringtheimpactof EDbuprenorphinetreatmentonoperationalmetrics.

METHODS

Weperformedaretrospectivecohortstudyofadult(age ≥18)EDpatientswithopioidusedisorder(OUD)discharged fromanyoftheacademic(one)orcommunity(11)hospitalbasedEDswithinalargehealthcaresystembetweenJanuary 2020–May2021.Thestudywasapprovedbyour institutionalreviewboardforsecondarydataanalysisofa completedqualityimprovementproject.

ToidentifyEDpatientswithOUDwhomaybenefitfrom buprenorphinetreatment,weappliedanelectronichealth record(EHR)computablephenotypepreviouslydevelopedand validatedbyChartashetal.10 Datawereextractedbyquerying anEDanalyticsdatamartpopulatedbyanightlyextractfrom theEpicClarity(EpicSystemsCorporation,Verona,WI) database.PatientswereidentifiedbysearchingfromphenotypespecificdiagnosiscodesandEDchiefcomplaints.Pertinent codesincludedInternationalClassificationofDiseases,10th Rev,ClinicalModification(ICD-10)diagnosticcodesrelating toopioiduse(T40.0*,T40.1*,T40.2*,T40.3*,T40.4*,T40.6*, andF11*)codedbyeitherthetreatingclinicianorsubsequently byamedicalcoder.Weadditionallyincludedpatientsnot identifiedbyICD-10diagnosticcodeEDchiefcomplaints relatingtoopioiduse.Chiefcomplaintdataisenteredintothe EHRattimeofEDencounterfromaprepopulatedlist,limiting ourselectionofsearchterms.Withinthelimitsofourdatabase, inclusionofencounterscontaining “opioid” or “naloxone” mostcloselyreflectedoriginalphenotypeterminology.Per phenotype,patientswiththeterms “benzodiazepine” or “alcohol” intheirEDdischargediagnosiswereexcludedto limitfalsepositiveinclusion.

Encounter-leveldataextractedincludedthefollowing: patientdemographics;chiefcomplaint;disposition;ED lengthofstay(LOS);dosesofmedicationsadministeredand prescribed;andfollow-upinformation,including30-dayED

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue? Understandingtheimpactofemergency department(ED)buprenorphineon operationscaninformresourceallocation decisionsforEDbuprenorphine programdevelopment.

Whatwastheresearchquestion?

HowdoesEDbuprenorphineimpact operations?HowdoEDoperational characteristicsimpacttreatmentrates?

Whatwasthemajor ﬁndingofthestudy?

Asmallnumberofpatientswithopioduse disorderwereprescribedbuprenorphine(2.5%in smallhospitals,11.6%inlargehospitals).ED lengthofstayand30-dayreturndidnotdiffer basedonbuprenorphinetreatment.

Howdoesthisimprovepopulationhealth?

DepartmentalleadershipcanprioritizeED buprenorphineprogramdevelopmentwithout fearofnegativeoperationalimpactto increaseaccesstolifesavingtreatment.

returnrateandnumberofdaysuntilEDreturnwithinthe samehealthsystem.Alldatawasdeidentiﬁedforanalysisby theresearchteam.

TheprimaryoutcomeofinterestwasEDbuprenorphine treatment,deﬁnedaspercentageofpatientsadministered buprenorphineduringand/orprescribedbuprenorphineas partoftheEDvisitamongallpatientswithOUDidentiﬁedby theEHRphenotype.Afterconsultingwithkeyadministrative leadersandsystemstakeholders,wepartitionedEDsbasedon operationalcharacteristicsincludingannualEDcensus; hospitalandintensivecareunit(ICU)admissionrates;median EDLOS(timefromEDarrivaltoEDdeparture);andmedian boardingtime(timefromadmissionorderplacedtoED departure).Hospitalsweredividedintotertilesforeach characteristic.Asnopowerorsensitivityanalyseswere performed,andourgoalwasdescriptiveandhypothesisgenerating,wedidnotperformhypothesis-testing comparativeanalyses.Statisticalanalyseswereperformed usingRStudioversion4.0.5(RStudioPBC,Boston,MA)and IBMSPSS26(SPSS,Inc,Chicago,IL).

RESULTS

The2021annualcensusforthe12EDsrangedfrom8,934 to103,381patients.Among541,962totaluniqueED

Table1. Characteristicsofcohortofpatientswithopioidusedisorder.

EDbuprenorphinetreatment

YesNo

Totalencounters541,9627596,710

Gender

Male243,961(46.9)436(57.4)3,528(52.6)

Female286,504(52.9)323(42.6)3,182(47.4)

Notreporting1,497(0.3)00

Race

Black55,975(10.3)91(12)610(9.1)

White374,736(69.1)537(70.8)5,094(75.9)

Anotherrace111,251(20.5)131(17.3)1,006(15)

Insurancestatus

Self-pay62,124(11.5)3(0.4)22(0.3)

Medicare/Medicaid307,513(56.7)589(77.6)4,955(73.8)

Otherinsurer163,489(30.2)162(21.3)1,648(24.6)

VA8,836(1.6)5(0.7)85(1.3)

Averagebuprenorphinedose(mg)

AdministeredN/a76.28N/a PrescribedN/a103.42N/a

EncounterswithnaloxoneprescriptionN/a268(45.5)1,041(21)

*Percentagesnotedinparentheses

ED,emergencydepartment; VA,VeteransAdministration; mg,milligrams.

encountersacrosssitesfromJanuary1,2020–May31,2021, 7,469(1.4%)visitswerephenotypepositiveandconstituted ourstudypopulation,representing5,637uniquepatients, withameanof622visitsperEDsite(range51–2,547). Phenotype-positivepatientswerepredominantlyWhite (75.4%)andmale(53.1%)(Table1).Aminority(759,10.2%) weretreatedwithbuprenorphineduringtheEDencounter, 695ofwhom(91.6%)receivedbuprenorphineadministered intheED,301(40%)receivedabuprenorphineprescription, and237(31.2%)receivedboth.

BuprenorphinewasadministeredintheEDmore frequentlythanitwasprescribedatdischarge,irrespective ofoperationalcharacteristics.Largerhospitalsandthose withhigherhospitalandICUadmissionrateshadhigher buprenorphinetreatmentrates(Table2).EDsexperiencing longerboardingtimesalsotrendedtowardhigherrates oftreatment.

MedianEDLOSwassimilaramongpatientstreatedwith buprenorphineversusnottreated,althoughconﬁdence intervalswerewide(Table3).Loweradmissionrate,smaller EDsize,andsmallervolumewereassociatedwithlongerED LOSforpatientstreatedwithbuprenorphine.Proportionof patientsreturningtotheEDwithin30daysandtimetoED returndidnotdifferconsistentlybasedontreatment withbuprenorphine.

DISCUSSION

Withinthissinglehealthsystem,weobservedthatED buprenorphinetreatmentratesvariedaccordingtothe baselineoperationalcharacteristicsoftheED,whichmay beaproxyfortheprogressivenessorphilosophical approachofagivenED’ slocalchampionsandleadership team.Weobservedlowerratesofbuprenorphinetreatment inEDswithsmallerannualcensusandloweracuity(as measuredbyoverallandICUadmissionrates),whichare presumablypracticesettingswheretheremaybeless perceptionofinsuf ﬁ cienttime.However,smallerEDsare lesslikelytohavemultipleprescribingcliniciansworking simultaneously.Priorstudieshavesuggestedthatpractice variationportendslowerqualitycareandinequitiesin accesstoeffectivetreatmentforOUD. 11 ,12 Ourdata supportstheneedforinterventionsdesignedtopromote buprenorphinetreatmentinsmaller,loweracuityEDsto narrowthisvariation.

Buprenorphinetreatmentdidnotappeartohavea consistentassociationwithEDLOS,incontrastto commonlycitedbarriers.9 Thirty-dayreturnratesandtime toEDreturnweresimilarbetweenpatientswithOUD, regardlessoftheirtreatmentwithbuprenorphine,afarcry fromcitedfearsofEDsbecoming “ overrun ” bypatients seekingbuprenorphinereﬁlls.13

Table2. Buprenorphineadministrationandprescription,categorizedbyemergencydepartmentoperationalcharacteristics.

Average valueper quantile(SD) OUD visits (n = 7,469)

AnnualED censusvolume Patients

Small(n = 4)11,424 (±2,413)

Buprenorphine administered (n = ,%) Buprenorphine prescribed (n = ,%)

Administered and prescribed (n = ,%) Any buprenorphine (n = ,%) No buprenorphine (n = ,%)

2456(2.4%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)29,351.5 (±5,715) 1,24561(4.9%)2(0.2%)2(0.2%)61(4.9%)1,184(95.1%)

Large(n = 4)69,739 (±30,656)

EDnumberof beds Beds

5,979628(10.5%)298(5%)234(3.9%)692(11.6%)5,287(88.4%)

Small(n = 4)10.25(±2.5)2456(2.4%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)21(±4.34)1,24561(4.9%)2(0.2%)2(0.2%)61(4.9%)1,184(95.1%)

Large(n = 4)49.5(±17.23)5,979629(10.5%)298(5%)234(3.9%)692(11.6%)5,287(88.4%) Hospital admissionrate Rate

Low(n = 4)7.90% (±4.7%) 52726(4.9%)1(0.2%)1(0.2%)26(4.9%)501(95.1%)

Middle(n = 4)16.98% (±1.8)

High(n = 4)27.41% (±3.2%)

ICUadmission rate Rate

1,745115(6.6%)6(0.3%)4(0.2%)117(6.7%)1,628(93.3%)

5,197554(10.7%)294(5.7%)232(4.5%)616(11.9%)4,581(88.2%)

Low(n = 4)0.2%(±0.4%)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)1.8%(±0.3%)2,027135(6.7%)6(0.3%)4(0.2%)137(6.8%)1,890(93.2%)

High(n = 4)3.1%(±0.6%)5,197554(10.7%)294(5.7%)232(4.5%)616(11.9%)4,581(88.2%) EDlengthofstayMinutes

Short(n = 4)106.3(±8.6)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)149.8(±4.7)4,216587(13.9%)287(6.8%)225(5.3%)649(15.4%)3,567(84.6%)

Long(n = 4)160.5(±2.1)3,008102(3.4%)13(0.4%)11(0.4%)104(3.5%)2,904(96.5%) MedianED boardingtime Minutes

Short(n = 4)59.5(±10.2)2456(2.5%)1(0.4%)1(0.4%)6(2.5%)239(97.6%)

Middle(n = 4)78.4(±4.6)1,43791(6.3%)2(0.1%)2(0.1%)91(6.3%)1,346(93.7%)

Long(n = 4)110.5(±24)5,787598(10.3%)298(5.2%)234(4%)662(11.4%)5,125(88.6%)

ED,emergencydepartment; ICU,intensivecareunit; OUD,opioidusedisorder.

Supportfromkeydepartmentalstakeholdersisa repeatedlyidentiﬁedfacilitatorforimplementingED buprenorphineprograms,andourobservationscorroborate this ﬁnding.13 IfLOSandEDreturnratearerelatively unaffectedbyEDbuprenorphinetreatment,thishas importantimplicationsthatmightallowdepartmental leaderstopromotegreaterresourcingandmitigatesomeof

theirapprehensionstofacilitatebuprenorphinetreatment withoutfearofnegativeoperationalimpacts.

LIMITATIONS

Ourstudyintentwasdescriptiveandshouldbeconsidered hypothesis-generating.Theuseofsecondarydatalimitedour abilitytopowerthestudy,and95%conﬁdenceintervalswere

Table3. EmergencydepartmentoperationaloutcomesbyEDoperationalcharacteristics.

EDOUDlengthofstay(minutes)30-DayEDOUDreturnvisitsDaysbeforeEDOUDreturn

Buprenorphine95%CI

AnnualEDcensusvolume

Small(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)250.4(211.8,289)263.7(251.1,276.3)14(1.8%)318(4.7%)8.7(4.7,12.8)11.2(10.2,12.2)

Large(n = 4)238(216.9,259.1)275.6(268.4,282.7)203(26.8%)1525(22.7%)11.5(10.2,12.67)11(10.6,11.5)

EDnumberofbeds

Small(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)250.4(211.8,289)263.7(251.1,276.3)14(1.8%)318(4.7%)8.7(4.7,12.8)11.2(10.2,12.2)

Large(n = 4)238(216.9,259.1)275.6(268.4,282.7)203(26.8%)1525(22.7%)11.5(10.2,12.7)11(10.6,11.5)

Hospitaladmissionrate

Low(n = 4)258(212.4,303.7)245.2(225.1,265.3)6(0.8%)156(2.3%)7.8(4.7,11)10.4(9.1,11.8)

Middle(n = 4)266(224.9,306.1)287(276.1,297.9)33(4.4%)461(6.9%)9.3(6.3,12.2)10.2(9.4,10.9)

High(n = 4)233.4(210.7,256.1)266.8(259.1,274.6)179(23.6%)1307(19.5%)11.7(10.4,13)11.3(10.8,11.7)

ICUadmissionrate

Low(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)264.1(228.8,299.5)289.2(278.9,299.6)38(5%)536(8%)9.1(6.5,11.7)10.5(9.8,11.2)

High(n = 4)233.4(210.7,256.1)266.8(259.1,274.6)179(23.6%)1307(19.5%)11.7(10.4,13)11.3(10.8,11.7)

EDlengthofstay

Short(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)225.8(205.2,246.3)279.7(271.6,287.9)187(24.6%)1059(15.8%)11.3(10.1,12.6)11.1(10.6,11.6)

Long(n = 4)321.7(261.8,381.6)265.5(255.8,275.3)30(4%)784(11.7%)11(7.9,14.1)11(10.4,11.6)

MedianEDboardingtime

Short(n = 4)264(148.2,379.8)181.6(159.4,203.8)1(0.1%)81(1.2%)7N/a8.5(6.8,10.3)

Middle(n = 4)285.9(242.6,329.2)300.6(285.8,315.4)27(3.6%)370(5.5%)9(6,12)11.4(10.5,12.3)

Long(n = 4)232.6(211,254.1)266.2(259.3,273.1)190(25%)1473(22%)11.6(10.3,12.9)11(10.5,11.4)

ED ,emergencydepartment; ICU ,intensivecareunit; OUD ,opioidusedisorder.

oftenwide.Treatmentratesmaybefalselyloweredbythe presenceofpatientsalreadyontreatmentand,therefore,not offeredED-basedbuprenorphine,althoughthiswouldbe unlikelytoimpactcomparisonbetweensites.Ourdatasetis alsolimitedbysizeandconﬁnementtoasinglehealthsystem aswellaslackofpatientdiversity,whichmaylimit generalizability.Importantly,unmeasuredoperationaland culturalfactorsmaypromptanygivenED’sleadershipteam tosupportbuprenorphinetreatment,andmanyofthose samefactorslikelyinﬂuencethegeneraloperational characteristicsoftheED.

WhilethishealthsystemoperatesonacommonEHR, cliniciansareallemployedbythehealthsystem,and incentivesatallsitesaretiedtorelativevalueunits,thereisa strongelementoflocalcontrolovertheoperationsofeach localED,withlittleadmixingofstafforoperational processesbetweenthem.Nevertheless,cliniciansmayhave movedbetweensitesorworkedatmultiplesites.Theremay beunmeasuredtemporaltrendsduringthestudyperiod,and aminorityofmoreprogressiveEDs(includingonlyone academicED)mayhavecontributeddisproportionatelyto our ﬁndings.Finally,ourpartitioningofEDsby organizationalmetricswasbasedoninternalcomparisons speciﬁctoourhealthcaresystem.Attemptstousenational benchmarkingdatafromtheAcademyofAdministratorsin AcademicEmergencyMedicineorEmergencyDepartment BenchmarkingAlliancewereunsuccessful,asnationalmean andmedianmetricscreatedseverelyunevengroupsizes. Whileourapproachmaylimitgeneralizabilitytoother healthcaresystems,itstillmayhaveimplicationsforfuture hypothesis-testingresearch.

CONCLUSION

TheevidencesupportingthesocietalbeneﬁtofED initiationofbuprenorphineforpatientswithopioiduse disorderisclear,butEDoperationalleadershipand stakeholderbuy-iniskeytoincreasingimplementation. Basedonourstudyresults,wehypothesizethatED buprenorphinetreatmentratesvariedbasedonoperational characteristicsofEDs,withlowertreatmentratesatsmaller, loweracuityfacilities.Wedidnotobserveconsistent differencesinlengthofstayorreturnvisits.Futureresearch willallowdepartmentalleadershiptocontinueprioritizing theevidence-basedpracticeofEDbuprenorphinetreatment todecreasevariabilitywhileimprovingqualityofcareand accesstolife-savingtreatmentforpatientswithOUD.Thisis particularlyimportantgiventherecentremovalofthe X-waiverrequirement.

AddressforCorrespondence:GrantComstock,MD,Departmentof EmergencyMedicine,MedicalCollegeofWisconsinHubfor CollaborativeMedicine,8701WatertownPlankRd,Milwaukee,WI 53226.Email: gcomstock@mcw.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Thedataforthisstudywereabstracted fromapreviouslycompletedqualityimprovementprojectfundedvia the2021EMF/NIDAMentor-FacilitatedTrainingAwardinSubstance UseDisordersScience.Therearenootherconflictsofinterestor sourcesoffundingtodeclare.

REFERENCES

1.AhmadFB,CisewskiJA,RossenLM,etal.Provisionaldrugoverdose deathcounts.2024.Availableat: https://www.cdc.gov/nchs/nvss/vsrr/ drug-overdose-data.htm.AccessedJanuary5,2024.

2.MattickRP,BreenC,KimberJ,etal.Buprenorphinemaintenance versusplaceboormethadonemaintenanceforopioiddependence. CochraneDatabaseSystRev. 2014;(2):CD002207.

3.LarochelleMR,BernsonD,LandT,etal.Medicationfor opioidusedisorderafternonfatalopioidoverdoseand associationwithmortality:acohortstudy. AnnInternMed. 2018;169(3):137–45.

4.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence:a randomizedclinicaltrial. JAMA. 2015;313(16):1636–44.

5.BuschSH,FiellinDA,ChawarskiMC,etal.Cost-effectivenessof emergencydepartment-initiatedtreatmentforopioiddependence. Addiction. 2017;112(11):2002–10.

6.StevensMA,TsaiJ,SavitzST,etal.Trendsanddisparitiesinaccessto buprenorphinetreatmentfollowinganopioid-relatedemergency departmentvisitamonganinsuredcohort,2014–2020. JAMANetwOpen. 2022;5(6):e2215287.

7.HollandWC,LiF,NathB,etal.Racialandethnicdisparitiesin emergencydepartment-initiatedbuprenorphineacross ﬁvehealthcare systems. AcadEmergMed. 2023;30(7):709–20.

8.WakemanSEandRichJD.Barrierstomedicationsfor addictiontreatment:howstigmakills. SubstUseMisuse. 2018;53(2):330–3.

9.ZuckermanM,KellyT,HeardK,etal.Physicianattitudeson buprenorphineinductionintheemergencydepartment:resultsfroma multistatesurvey. ClinToxicol(Phila). 2021;59(4):279–85.

10.ChartashD,PaekH,DziuraJD,etal.Identifyingopioidusedisorderin theemergencydepartment:multi-systemelectronichealthrecordbasedcomputablephenotypederivationandvalidationstudy. JMIR MedInform. 2019;7(4):e15794.

11.BrothersTD,MosselerK,KirklandS,etal.Unequalaccesstoopioid agonisttreatmentandsterileinjectingequipmentamonghospitalized patientswithinjectiondruguse-associatedinfectiveendocarditis. PLoSOne. 2022;17(1):e0263156.

12.AmiriS,McDonellMG,DenneyJT,etal.Disparitiesinaccesstoopioid treatmentprogramsandofﬁce-basedbuprenorphinetreatmentacross therural-urbanandareadeprivationcontinua:aUSnationwidesmall areaanalysis. ValueHealth. 2021;24(2):188–95.

13.RosenbergNK,HillAB,JohnskyL,etal.Barriersandfacilitators associatedwithestablishmentofemergencydepartment-initiated buprenorphineforopioidusedisorderinruralMaine. JRuralHealth. 2022;38(3):612–9.

SUBSTANCE ABUSE

ImpactofEmergencyDepartment-InitiatedBuprenorphineon RepeatEmergencyDepartmentUtilization

RachelM.Skains,MD,MSPH*†

LindyReynolds,MSGH*

NicholasCarlisle,JD‡

SonyaHeath,MD§

WhitneyCovington,MPH,MLS*

KyleHornbuckle∥

LaurenWalter,MD*

*UniversityofAlabamaatBirmingham,HeersinkSchoolofMedicine,Department ofEmergencyMedicine,Birmingham,Alabama

† BirminghamVAMedicalCenter,DepartmentofEmergencyMedicine, Birmingham,Alabama

‡ UniversityofAlabamaatBirmingham,SchoolofPublicHealth,Departmentof HealthBehavior,Birmingham,Alabama

§ UniversityofAlabamaatBirmingham,HeersinkSchoolofMedicine,Department ofInternalMedicine,Birmingham,Alabama

∥ UniversityofAlabamaatBirmingham,HeersinkSchoolofMedicine, Birmingham,Alabama

SectionEditors: AlexisLapietra,MD,andR.Wilkerson,MD

Submissionhistory:SubmittedMarch30,2023;RevisionreceivedSeptember26,2023;AcceptedSeptember27,2023

ElectronicallypublishedNovember8,2023

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.60511

Introduction: Recentstudieshavedemonstratedthepromiseofemergencydepartment(ED)-initiated buprenorphine/naloxone(bup/nx)forimproving30-dayretentioninoutpatientaddictioncareprograms forpatientswithopioidusedisorder(OUD).WeinvestigatedwhetherED-initiatedbup/nxforOUDalso impactsrepeatEDutilization.

Methods: WeperformedaretrospectivechartreviewofEDpatientsdischargedwithaprimarydiagnosis ofOUDfromJuly2019–December2020.Characteristicsconsideredincludedage,gender,race, insurancestatus,domicilestatus,presenceofcomorbidDiagnosticandStatisticalManualofMental Disorders,FifthEdition(DSM-5)diagnosis,presentingchiefcomplaint,andprovisionofabup/nx prescriptionand/ornaloxonekit.PrimaryoutcomesincludedrepeatEDvisit(opioidornon-opioidrelated) within30days,90days,andoneyear.Statisticalanalysesincludedbivariatecomparisonand Poissonregression.

Results: Of169participants,themajorityweremale(67.5%),White(82.8%),uninsured(72.2%),andin opioidwithdrawaland/orrequesting “detox” (75.7%).Ninety-one(53.8%)receivedED-initiatedbup/nx, whichwasindependentofage,gender,race,insurancestatus,presenceofcomorbidDSM-5diagnosis, ordomicilestatus.Naloxonewasmorelikelytobeprovidedtopatientswhoreceivedbup/nx(97.8%vs 26.9%; P < 0.001),andbup/nxwasmorelikelytobegiventopatientswhopresentedwithopioid withdrawaland/orrequested “detox” (63.3%vs36.7%; P < 0.001).Bup/nxprovisionwasassociatedwith decreasedEDutilizationforopioid-relatedvisitsat30days(P = 0.04).Homelessnessandlackof insurancewereassociatedwithincreasedEDutilizationfornon-opioid-relatedvisitsat90days (P = 0.008and P = 0.005,respectively),andagainatoneyearforhomelessness(P < 0.001).When controllingforageanddomicilestatus,theadjustedincidencerateratioforoverallEDvisitswas0.56 (95%conﬁdenceinterval[CI]0.33–0.96)at30days,0.43(95%CI0.27–0.69)at90days,and0.60(95% CI0.39–0.92)atoneyear,favoringbup/nxprovision.

Conclusion: Initiationofbup/nxintheEDsettingwasassociatedwithdecreasedsubsequentED utilization.Socioeconomicfactors,specificallyhealthinsuranceanddomicilestatus,significantly impactednon-opioid-relatedEDreuse.These findingsdemonstratetheED’spotentialasaninitiation pointforbup/nxandhighlighttheimportanceofconsideringthesocialriskandsocialneedforOUD patients.[WestJEmergMed.2025;26(1.1)63–70.]

INTRODUCTION

AccordingtotheSubstanceAbuseandMentalHealth ServicesAdministration,nearly5.6millionresidentsofthe UnitedStateshadopioidusedisorder(OUD)in2021, accountingfor2%oftheUSpopulation.1 From2020to 2021,therewereanestimated1.8millionnewusersof prescriptionpainrelieversand26,000newheroinusers,or nearly5,000newopioidusersperday.1 Correspondingly,the USCentersforDiseaseControlandPreventionobserveda recordhighdrugoverdosemortalityin2021,withover 107,000drugoverdosedeathsintheUS,morethan80,000of whichinvolvedopioids.2

ThestateofAlabamahasbeenparticularlyaffectedbythe opioidepidemic.Since2014,Alabamahasledthenation withthehighestrateofopioidprescriptionsinthecountry (80.4prescriptionsforevery100personsin2020), approximatelytwofoldgreaterthanthenationalaverage.3 JeffersonCounty,thestate’smostpopulouscounty,hadthe highestnumberofopioidoverdosedeathsinAlabamain 2021,with342conﬁrmedopioidoverdosedeaths,a44.7% increasefrom2020.4 Theopioidepidemicisanongoing, signiﬁcantpublichealthemergencyasevidencedbytherising incidenceofopioidmisuse,OUD,andopioid-relateddeaths intheUS.

Emergencyphysiciansareuniquelypositionedtohelp combatthegrowingopioidcrisisbyscreeningandinitiating careforpatientspresentingtotheemergencydepartment (ED)withOUD.Opioid-relatedEDvisitshaveincreased, representingnearlyonein80EDvisits,andescalated dramaticallyduringthecoronavirusdisease2019(COVID19)pandemicwhennon-opioid-relatedEDvisits decreased.5,6 Importantly,screeningforopioidmisuseand dependenceintheEDhasbeenproventopositivelyaffectthe prognosisofthesepatients.Inalandmarkrandomized clinicaltrialin2015,D’Onofrio andcolleaguesdemonstratedthatEDscreening,brief intervention,andreferraltotreatment(SBIRT)forOUD, includingED-initiatedmedicationsforOUD(MOUD)with buprenorphine/naloxone(bup/nx),signiﬁcantlyincreased 30-dayretentioninoutpatientaddictiontreatment, decreasedtheuseofopioids,anddecreasedutilization ofinpatientaddictionservices.7 AsMOUDhasbeen recognizedasaneffectivetreatmentoptiontoreduce mortality,overdose,andcost,EDsareincreasinglyengaged inOUDtreatmentinitiation.8–14 Further,arecent community-basedstudybyLeetaldemonstrateddecreased subsequenthealthcareutilizationat12monthsafter initiationofMOUDintheED.15

MostED-initiatedMOUDstudieshavefocusedon treatmentretentioninlarge,urban,academicmedicalcenters outsidetheSoutheastorsubsequenthealthcareutilizationin communityhospitals.7,11,12,15,16 Ourlarge,urban,academic EDintheSoutheastoffersauniqueperspectiveontheimpact

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Emergencydepartment(ED)-initiated buprenorphine/nalox one(bup/nx)improves 30-dayretentioninoutpatientaddiction programsforopioidusedisorder(OUD).

Whatwastheresearchquestion?

DoesED-initiatedbup/nxforOUDalsoimpact acutehealthcareutilization,speciﬁcallyrepeat EDvisits,forOUDpatients?

Whatwasthemajorquantitative ﬁnding ofthestudy?

Bup/nxdecreasedEDutilizationat30days (37.5%vs.62.5%,P < 0.05).Homelessness andlackofinsuranceincreasedEDutilization at90days(P < 0.01).

Howdoesthisimprovepopulationhealth?

FindingsshowtheED ’ spotentialasan initiationpointforbup/nxandhighlightthe importanceofsocialriskandneedfor OUDpatients.

ofED-initiatedMOUDonhealthcareutilizationina resource-limitedregioncharacterizedbypersistentMedicaid non-expansion,highpovertyrates,andhealthcareaccess challenges.13 Inthisstudy,weinvestigatedwhetherEDinitiatedbup/nxalsoimpactsacutehealthcareutilization, speciﬁcallyrepeatEDvisits,forEDOUDpatients.

METHODS

StudyDesignandSetting

Weconductedaretrospectivechartreviewofpatientswho presentedtooururbanacademicmedicalcenterEDatthe UniversityofAlabamaatBirmingham(UAB)andwere dischargedfromtheEDwithadiagnosisofOUD,using InternationalClassiﬁcationofDiseases,10th Revision,(ICD10)codedocumentation.17 WeobtainedUABInstitutional ReviewBoardapproval.Our48-bed,tertiarycareED evaluatesover75,000patientsannually.TheUABHospital has1,157licensedbedsandservesastheprimaryhospitalfor north-centralAlabamaandsurroundingareas.Weselected thestudyperiodJuly2019–June2020becauseitmarkedthe inauguralyearofthehospital’sED-initiatedOUDprogram, wherepatientswithadiagnosisofOUDweretobedischarged withabridgebup/nxprescription,naloxonetake-homekit, andreferraltooutpatientaddictiontreatment.However,

emergencyclinicians’ uptakeandutilizationofthebup/nx prescriptionwasnotuniversalduringthat ﬁrstyear.Priorto July2019,bup/nxwasnotroutinelyprescribedfromtheED.

StudyVariables

TheprimaryoutcomesofinterestwererepeatED utilizationwithin30days,90days,andoneyearoftheinitial EDvisit.RepeatEDvisitswerefurtherclassiﬁedaseither opioid-relatedornon-opioid-related,asdeﬁnedbyICD-10 documentation.17 Whenanalyzingopioid-relatedEDvisits andnon-opioid-relatedEDvisitsseparately,weconsidered outcomesateachtimepointasbinaryvariables.Thenumber ofopioid-relatedrepeatEDvisitswasaddedtothenumberof non-opioid-relatedEDvisitswithin30days,90days,andone yeartoobtainthecompositeoutcomeoftotalrepeatED visitsateachtimepointofinterest.Weusedcompositevalue forPoissonregressionanalysis.Theprimaryexposureof interestwaswhetherthepatientwasdischargedwith abup/nxprescription,whichwasabinaryvariablecodedas yesorno.

Othervariablesintheanalysisincludedage,gender,race, healthinsurancestatus,domicilestatus,provisionofa naloxonekit,comorbidDiagnosticandStatisticalManualof MentalDisorders,FifthEdition(DSM-5)diagnosis,and presentingchiefcomplaintattheinitialEDvisit.Agewas measuredinyearsandwasexaminedasacontinuous variable.Genderwasdeterminedbydatarecordedinthe electronichealthrecord(EHR)atthetimeofED registration,typicallydictatedbyavailablelegal identification(eg,driver’slicense)orself-reportedinabsence ofID.Genderwasanominalvariableclassifiedasmale, femaleorother,perEHRlimitations.Racewascategorized asWhiteorBlack.(Otherracialcategorieswerenot consideredduetolownumbers.)Healthinsurancewas definedasprivate,public(Medicareand/orMedicaid),or self-pay(uninsured).Domicilestatuswasabinaryvariable andclassifiedaseitherhomelessornothomeless.The provisionofanaloxonekitupondischargefrominitialvisit wasincludedasadichotomousyesornovariable,aswasthe presenceofacomorbidDSM-5mentalhealthdiagnosis. Concomitantmentalhealthdiagnosiswasdeterminedby presencein “pastmedicalhistory” duringchartreview.Chief complaintattheinitialEDvisitwasnotedandwasmanually classifiedbyreviewersasopioidwithdrawal/detoxification (“detox”)request,opioidoverdose,psychiatriccomplaint,or medicalcomplaint.

StatisticalAnalysis

WecarriedoutallanalysesusingSAS9.4(SASInstitute, Cary,NC),and P < 0.05wasconsideredstatistically signiﬁcant.18 Frequenciesandproportionsweretabulatedfor categoricalvariables,whichincludedgender,race,health insurance,naloxonekitprovision,buprenorphine prescription,comorbidDSM-5diagnosis,andEDchief

complaint.Wecalculatedmeanandstandarddeviationfor age,whichwastreatedasacontinuousvariable.Chi-square andFisherexacttestswereusedtocomparethecategorical demographicandmedicalcharacteristicsofthosewithvs thosewithoutarepeatopioid-relatedEDvisitwithin30days, 90days,oroneyear.Weused t -teststoassessdifferencesin agebyoutcomestatus.Identicalmethodswereusedforthe non-opioid-relatedEDvisitoutcomes(at30days,90days, andoneyear).CrudeandadjustedPoissonmodelswere constructedtoestimatechangesinthenumberoftotalrepeat EDvisitsaswellastheassociated95%conﬁdenceinterval (CI)betweenthosewhowereprescribedbup/nxandthose whowerenotattheindexEDvisitforeachofthetime periods(30days,90days,andoneyear).Separate modelsweregeneratedforeachoutcome.Althoughno overdispersioninthe30-daymodelwasobserved, overdispersioninthe90-dayandone-yearmodelswas detectedandwasaccountedforbyscalingbythedeviance. Secondaryanalysesexaminedwhethertheassociation betweenbup/nxprescriptionandtotalnumberofrepeatED visitsvariedbasedonwhetherthepatientalsoreceiveda naloxonekitattheirinitialEDvisit.Toaccomplishthis,we includedaninteractiontermbetweenbup/nxprescription andnaloxonekitineachofthemodels.Alladjustedmodels includedageanddomicilestatusascovariates.

RESULTS

Thisstudyincluded169OUDpatients.Ofthese, approximately67.5%weremaleand82.8%wereWhite. Mostpatientsdidnothavehealthinsurance(72.2%),and27 (15.9%)werehomeless(Tables1, 2).Additionally,over75% ofpatientspresentedtotheEDattheirinitialvisitinopioid withdrawalorrequesting “detox.” Ninety-onepatients (53.8%)receivedED-initiatedbup/nx(suboxone),and110 (65.1%)weregivenanaloxonekittotakehomeattheirinitial EDvisit.Abup/nxprescriptionwasmorelikelytobegivento patientswhopresentedinopioidwithdrawaland/or requested “detox” (63.3%vs36.7%; P < 0.001),butbup/nx prescriptiondidnotshowsigniﬁcantassociationswithage, gender,race,insurancestatus,presenceofco-morbidDSM-5 diagnosis,ordomicilestatus.Analoxonekitwasmorelikely tobeprovidedtopatientswhoreceivedbup/nx(97.8%vs 26.9%; P < 0.001).

At30days,32patients(18.9%)hadarepeatopioid-related EDvisit(Table1).Nosigniﬁcantdifferencesemergedin termsofage,gender,race,healthinsurancestatus, homelessness,EDchiefcomplaint,orcomorbidDSM-5 diagnosisrates.However,bup/nxprescriptionandnaloxone kitprovisionwereassociatedwithdecreasedEDutilization foropioid-relatedvisitsat30days(P = 0.04and P < 0.001, respectively).By90days,30.2%ofthestudysamplehada repeatopioid-relatedEDvisit.Inthistimeframe,male patients(P < 0.05)andthosewhodidnotreceiveanaloxone kit(P = 0.001)weremorelikelytohavearepeatvisit;

Table1. Comparisonofpatientcharacteristicsbywhetherthepatienthadarepeatopioid-relatedemergencydepartmentvisit.

Variables 30-DayrepeatEDvisit90-DayrepeatEDvisit1-YearrepeatEDvisit

Gender,n(%)

Female49(35.8)6(18.8)0.0644(37.3)11(21.6) <0.05*35(34.3)20(29.8)0.54

Male88(64.2)26(81.2)74(62.7)40(78.4)67(65.7)47(70.2)

Race,n(%)

White113(83.7)27(84.4)0.7997(83.6)43(84.3)0.6486(86.0)13(19.4)0.33

Black22(16.3)5(15.6)19(16.4)8(15.7)14(14.0)54(80.6)

HealthIns,n(%)

Private18(13.1)2(6.2)0.4915(12.7)5(9.8)0.8614(13.7)6(9.0)0.43

Public23(16.8)4(12.5)19(16.1)8(15.7)18(17.6)9(13.4)

Self-pay96(70.1)26(81.3)84(71.2)38(74.5)70(68.6)52(77.6)

Homeless,n(%)

No117(85.4)25(78.1)0.31103(87.3)39(76.5)0.0890(88.2)52(77.6)0.07 Yes20(14.6)7(21.9)15(12.7)12(23.4)12(11.8)15(22.4)

Naloxonekitgiven,n(%)

No39(28.5)20(62.5) <0.001*32(27.1)27(52.9)0.001*28(27.4)31(46.3)0.01* Yes98(71.5)12(37.5)86(72.9)24(47.1)74(72.6)36(53.7)

BuprenorphineRx,n(%)

No58(42.3)20(62.5)0.04*51(43.2)27(52.9)0.2445(44.1)33(49.2)0.51

Yes79(57.7)12(37.5)67(56.8)24(47.1)57(55.9)34(50.8)

ComorbidDSM-5Dx,n(%)

No116(84.7)28(87.5)0.6898(83.0)46(90.2)0.2384(82.4)60(89.6)0.20

Yes21(15.3)4(12.5)20(17.0)5(9.8)18(17.6)7(10.4)

EDchiefcomplaint,n(%)

OpioidWD/detoxrequest102(74.4)26(81.2)0.5288(74.6)40(78.4)0.2377(75.5)51(76.1)0.30

OpioidOD21(15.3)2(6.2)19(16.1)4(7.8)15(14.7)8(11.9)

Psychiatriccomplaint9(6.6)2(6.2)8(6.8)3(5.9)8(7.8)3(4.5)

Medicalcomplaint5(3.7)2(6.2)3(2.5)4(7.8)2(2.0)5(7.5)

Raceinformationwasmissingfortwopatients.

ED,emergencydepartment; Detox,detoxiﬁcation; DSM-5,DiagnosticandStatisticalManualofMentalDisorders,5thEdition; Dx,diagnosis; Ins,insurance; OD,overdose; Rx,prescription; WD,withdrawal.

*Denotesstatisticalsigniﬁcancewhere P < 0.05.

however,ED-prescribedbup/nxwasnolongersigniﬁcantly associatedwithhavingarepeatvisit(P = 0.24).

Withinoneyear,67patients(40.0%)hadarepeatopioidrelatedEDvisit.Inthistimeframe,theonlyvariableshowing asigniﬁcantassociationwithrepeatEDvisitwasnaloxone kitprovision(P = 0.01).Ofthosewhoreceivedanaloxone kit,32.7%hadarepeatvisit;however,amongthosewhodid notreceiveakit,52.5%hadarepeatvisit.Thus,naloxonekit provisionwasassociatedwithdecreasedEDutilizationfor opioid-relatedvisitsat30days,90days,andoneyear (P < 0.001, P = 0.001,and P = 0.01,respectively).Ofthe169 patients,only11(6.5%)hadanon-opioid-relatedrepeatED

visitwithin30days(Table2),comparedwith32(18.9%)who hadanopioid-relatedrepeatEDvisitinthatsametime frame.Increasingagewasassociatedwitharepeatnonopioid-relatedvisitat30days(43.8 ± 8.9yearsvs36.3 ± 9.2years; P = 0.009).Atthistimepoint,nosigniﬁcant differencesemergedintermsofgender,race,health insurance,homelessness,naloxonekitprovision, bup/nxprescription,comorbidDSM-5diagnosis,orED chiefcomplaint.

By90days,thenumberofpatientswithanon-opioidrelatedrepeatEDvisitincreasedto23(13.6%).Thosewitha repeatvisitwereolder(P = 0.004),morelikelytobe

Table2. Comparisonofpatientcharacteristicsbywhetherthepatienthadarepeatnon-opioid-relatedEDvisit.

Variables 30-DayrepeatEDvisit90-DayrepeatEDvisit1-YearrepeatEDvisit

Gender,n(%)

Female53(33.5)2(18.2)0.5150(34.2)5(21.7)0.2343(34.4)12(27.3)0.39

Male105(66.5)9(81.8)96(65.8)18(78.3)82(65.6)32(72.7)

Race,n(%)

White130(83.3)10(90.9)0.75121(84.0)19(82.6)0.83103(83.7)37(84.1)0.70

Black26(16.7)1(9.1)23(16.0)4(17.4)20(16.3)7(15.9)

Healthins,n(%)

Private18(11.4)2(18.2)0.6817(11.6)3(13.0)0.005*15(12.0)5(11.4)0.36

Public25(15.8)2(18.2)18(12.3)9(39.1)17(13.6)10(22.7)

Self-pay115(72.8)7(63.6)111(76.0)11(47.8)93(74.4)29(65.9)

Homeless,n(%)

No134(84.8)8(72.7)0.39127(87.0)15(65.2)0.008*112(89.6)30(68.2)0.001* Yes24(15.2)3(27.3)19(13.0)8(34.8)13(10.4)14(31.8)

Naloxonekitgiven,n(%)

No55(34.8)4(36.4)0.9246(31.5)13(56.5)0.02*41(32.8)18(40.9)0.33

Yes103(65.2)7(63.6)100(68.5)10(43.5)84(67.2)26(59.1)

BuprenorphineRx,n(%)

No73(46.2)5(45.4)0.9664(43.8)14(60.9)0.1358(46.4)20(45.4)0.91 Yes85(53.8)6(54.6)82(56.2)9(39.1)67(53.6)24(54.6)

ComorbidDSM-5Dx,n(%)

No134(84.8)10(90.9)0.58123(84.2)21(91.3)0.53108(86.4)36(81.8)0.46

Yes24(15.2)1(9.1)23(15.8)2(8.7)17(13.6)8(18.2)

EDchiefcomplaint,n(%)

OpioidWD/detoxrequest118(74.7)10(90.9)0.62109(74.7)19(82.6)0.2993(74.4)35(79.6)0.32

OpioidOD22(13.9)1(9.1)21(14.4)2(8.7)20(16.0)3(6.8)

Psychiatriccomplaint11(7.0)0(0.0)11(7.5)0(0.0)8(6.4)3(6.8)

Medicalcomplaint7(4.4)0(0.0)5(2.4)2(8.7)4(3.2)3(6.8)

Raceinformationwasmissingfortwopatients.

ED,emergencydepartment; Detox,detoxiﬁcation; DSM-5,DiagnosticandStatisticalManualofMentalDisorders,5thEdition; Dx,diagnosis; Ins,insurance; OD,overdose; Rx,prescription; WD,withdrawal.

*Denotesstatisticalsigniﬁcancewhere P < 0.05.

uninsured(P = 0.005),morelikelytobehomeless(P = 0.008),andlesslikelytohavereceivedanaloxonekitatthe initialvisit(P = 0.02).Byoneyear,44patients(26%)hada repeatnon-opioid-relatedEDvisit.Again,patientswitha repeatvisitwereolder(P = 0.003)andmorelikelytobe homeless(P < 0.001),althoughinsurancestatusand naloxoneprovisionnolongershowedasigniﬁcant association(P = 0.36).

Next,thetotalrepeatall-causeEDvisitswereconsidered. Within30daysoftheirindexEDvisit,23.1%ofpatientshad atleastonerepeatall-causeEDvisit(range1–4visits).By90

days,thispercentageincreasedto35.5%(range1–12visits). Atoneyearfromtheinitialvisit,50.3%ofpatientshada repeatvisit(range1–36visits).Intheunadjustedmodels, bup/nxprescriptionprovisionwassignificantlyassociated withareductioninthenumberofrepeatall-causeEDvisits at90days(butnot30daysoroneyear)(Table3).Giventhat significantassociationwasalsoobservedbetweenolderage andhomelessnessandall-causerepeatEDvisits,thebup/nx association findingswerere-evaluatedafteradjustingforage anddomicilestatus.Afteradjustingforageanddomicile status,astrongerassociationemergedbetweenbup/nx

Table3. Countratiosand95%conﬁdenceintervalsfortheassociationbetweenbuprenorphine/naloxoneprescriptiongivenandnumberof all-causerepeatemergencydepartmentvisits.+

RepeatEDvisitwithin30daysRepeatEDvisitwithin90daysRepeatEDvisitwithin1year

Overall

Nobup/nxRefRefRefRefRefRef

Bup/nxgiven0.60(0.35–

Nonaloxonekitgiven

0.56(0.33–0.96)0.48(0.29–0.79)0.43(0.27–0.69) 0.66(0.42–1.05) 0.60(0.39–0.92)

Nobup/nxRefRefRefRefRefRef

Bup/nxgiven0.95(0.13–6.97)1.10(0.15–8.13)0.37(0.03–4.88)0.50(0.04–5.68)0.39(0.03–5.66)0.52(0.04–6.54)

Naloxonekitgiven

Nobup/nxRefRefRefRefRefRef

Bup/nxgiven1.73(0.52–5.78)1.50(0.45–5.07)3.46(0.75–15.97)2.67(0.63–11.28)2.38(0.76–7.44)1.85(0.63–5.44)

+Estimatesofcountratioand95%CIsgeneratedfromPoissonmodels.

*Boldfacefont indicatesstatisticalsigniﬁcancewhere P < 0.05.

1Adjustedforageanddomicilestatus.

ED,emergencydepartment; CI,conﬁdenceinterval; bup/nx,buprenorphine/naloxone; ref,reference.

prescriptionprovisionandrepeatall-causeEDvisits,with bup/nxprescriptionbeingassociatedwitha44%reductionin thenumberofrepeatall-causeEDvisitsat30days(adjusted incidencerateratio[IRR]:0.56,95%conﬁdenceinterval[CI] 0.33–0.96),a57%reductionat90days(adjustedIRR0.43, 95%CI0.27–0.69),anda40%reductionatoneyear (adjustedIRR0.60,95%CI0.39–0.92)(Table3).

DISCUSSION

ThisstudyhighlightstheimpactofOUDandtheopioid epidemicingeneralontheED.Overhalfthepatients includedinthisstudyhadarepeatEDvisitwithinoneyear. Thishighlevelofutilizationislikelydue,inlargepart,tothe overlappingsocialriskandsocialneedexperiencedbythis cohort.Thegeneraldemographiccharacteristicsofthisstudy populationaresimilartothenationalopioidepidemic landscape,predominantlyWhite(82.8%)andmale (67.5%).19 However,whenconsideringsocialfactors,suchas insuranceanddomicilestatus,ourOUDpopulationwas disproportionatelyaffectedbynegativesocialdeterminants ofhealth(SDoH).MorethansevenintenOUDpatients wereuninsured,comparedwiththeaverageuninsuredrateof 12.7%innon-expansionstatesin2021.20 Further,16%were homeless,whichisnearly100timesthenationalrate.21 Homelessnessandlackofinsurancewereindependently associatedwithincreasedEDutilizationfornon-opioidrelatedvisitsat90days(P = 0.008andp = 0.005, respectively),andagainatoneyearforhomelessness (P < 0.001).Thisunderscoresthecomplexsocialcontextof theEDOUDpopulation.Ifco-occurringSDoHdomainsare notaddressedduringtheEDvisit,MOUDmaynotbe successfulindecreasingsubsequenthealthcareutilization.

AtUABHospital,EDsocialworkersandcasemanagersare available24/7toprovidehousingandhealthcareaccess resourcestounderservedpatients;however,referralsto assistanceprogramsarenotconsistentlydocumentedin theEHR.

Althoughbup/nxprovisionwasassociatedwithdecreased EDutilizationforopioid-relatedvisitsat30days(P = 0.04), only53.8%receivedED-initiatedbup/nx.Further,bup/nx wasmorelikelytobegiventoOUDpatientswhopresented inopioidwithdrawaland/orrequesting “detox” (63.3%vs 36.7%; P < 0.001).Therearemanyplausibleexplanationsfor why46.2%ofOUDpatientsdidnotreceivebup/nxatthe initialEDvisit,althoughthispercentageismuchlowerthan arecentlypublishednationalretrospectivecohortstudy where91.5%werenotprescribedbuprenorphineafteranED visitforopioidoverdose.22 First,inJuly2019(studyperiod startdate),theUABDepartmentofEmergencyMedicine hadjustinitiatedtheDrugAddictionTreatmentAct of2000(DATA2000) “X-waiver” trainingrequirement tolicenseemergencycliniciansforMOUDprescribing bup/nxthroughanincentiveprogram,whichwas stronglyencouragedbutnotmandatedforallclinicians.23 Further,MOUDprogramuptakewasnotuniversaldue toseveralknownbarrierstoMOUDintheED,including lackoftrainingandexperienceinSBIRT,lackofavailability ofcloseoutpatientfollow-upinaddictiontreatmentcenters, andlimitedcliniciantimeinabusyED.24 Finally,notevery OUDpatientpresentingtotheEDwasacandidatefor MOUDwithbup/nxduetolackofmotivationtoseekand engageinoutpatienttreatment,concomitantuseofillicit depressiveagents,hypersensitivityreaction,andconcernfor diversion.25 ItisstandardpracticeattheUABEDfor

patientsreceivingED-initiatedMOUDtobereferredto communitytreatmentprograms;however,outpatient follow-upratesarenoteasilymeasuredwithinour currentsystem.

WhileroughlyhalfofthepatientsreceivedMOUDatthe initialEDvisit,nearlytwo-thirdsreceivedatake-home naloxonekit,which,atthetimeofthestudywasprovidedto patientsfreeofchargewithanemergencyphysician(EP) orderviaacollaborativeprojectwiththeJeffersonCounty HealthDepartment.Importantly,naloxonekitprovision wasassociatedwithdecreasedEDutilizationforopioidrelatedvisitsat30days,90days,andoneyear(P < 0.001, P = 0.001,and P = 0.01,respectively)andnon-opioid-related visitsat90days(P = 0.02).Naloxoneisapotentiallylifesaving,easy-to-useand,inthisinstance,freeintervention. Severalfactorsmighthavecontributedtoincomplete provision:1)ThenaloxonekitrequiredaspeciﬁcEPorderto bedispensed,whichmaynothavebeenprioritizeddueto competingdemandsforphysicianfocusandtime;2)EPsmay havehadmisperceptionsoftime-consumingcounseling accompanyingnaloxoneprovision;and3)EPsmayhave beenunawareoftheavailabilityofnaloxoneprovidedasa take-homekitratherthanaprescription.

Ingeneral,therewassigniﬁcantcollinearitybetweenbup/ nxandnaloxonekitprovision.Analoxonekitwasmorelikely tobeprovidedtopatientswhoreceivedbup/nx(97.8%vs 26.9%; P < 0.001).Further,bup/nxwasmorelikelytobegiven topatientswhopresentedinopioidwithdrawaland/or requested “detox:(63.3%vs36.7%; P < 0.001).However, patientswhopresentedinthemostsevereformofOUD,an acuteoverdose,werenotmorelikelytoreceivebup/nx.This maybeduetotheEP’sfocusonresuscitationofacute decompensationandrespiratorydepression,ratherthan engagementofabriefinterventionforMOUDtoassessa patient’smotivationtowardbehavioralchange.

OurstudyisuniqueinassessingwhetherED-initiatedbup/ nximpactssubsequentacutehealthcareutilization,while alsoevaluatingtheimpactofSDoH,suchashealthinsurance anddomicilestatus.Ourresultsshowedthatwhen controllingforageandhomelessness,initiationofbup/nxin theEDsettingwasassociatedwithdecreasedsubsequent all-causeEDutilization.Further,socioeconomicfactors, specificallyinsuranceanddomicilestatus,appeartohave significantimpactonnon-opioid-relatedEDreuse.These findingsdemonstratetheED’spotentialasaninitiationpoint forOUDtreatmentandhighlighttheimportanceof consideringsocialriskandsocialneedforOUDpatients intheED.

LIMITATIONS

Thisstudyhadseverallimitations.First,thestudydesign wasaretrospectivechartreview,whichpreventsabstractors frombeingblindedtothestudypurposeanddrawing conclusionsofcausality.However,tominimizebias,

establishedemergencymedicinechartreviewstudymethods wereadheredto.26 Further,thestudypopulationwas obtainedfromasinglesite,whichlimitsgeneralizability. RevisitstoEDsinoutsidehealthcaresystemswereunableto betracked,preventingcompletecapture.However,UAB Hospitalisthecatchmenthealthcaresystemforthestateof Alabamaprovidinghealthcareaccesstounderserved populations,includingtheCharityCareProgram, EqualAccessBirminghamfreeclinic,ProvidingAccess toHealthcareclinic,andaComprehensiveUrban UnderservedandRuralExperienceprogram.Finally, EDvisitratesforopioidoverdoseincreasedbyover25% in2020duetotheCOVID-19pandemic,despiteadecline inoverallEDvisits.27 Thus,expandedcommunity-and hospital-basedMOUDinterventionswereneededtosupport OUDpatientsduringtheCOVID-19pandemic;however, manycounselingandtreatmentclinicswereunavailable duringthattime.

CONCLUSION

Initiationofbuprenorphine/naloxoneintheEDsetting canresultindecreasedsubsequentEDutilization. Socioeconomicfactors,specificallyhealthinsuranceand domicilestatus,alsoappeartohaveasignificantimpacton EDreuse.These findingsdemonstratetheED’spotentialas aninitiationpointforprescribingmedicationforopioiduse disorderandhighlighttheimportanceofconsideringsocial riskandsocialneedforOUDpatients.

AddressforCorrespondence:RachelMSkains,MD,MSPH, UniversityofAlabamaatBirmingham,HeersinkSchoolofMedicine, DepartmentofEmergencyMedicine,17202nd Ave.South,GSB238, Birmingham,Alabama352494.Email: rskains@uabmc.edu

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Theprojectdescribedwassupportedby GrantNumber1H79T1081609-01fromtheSubstanceAbuseand MentalHealthServicesAdministration(SAMHSA).Itscontentsare solelytheresponsibilityoftheauthorsanddonotnecessarily representtheofficialviewsoftheSAMHSA.Therearenoconflictsof interesttodeclare.

REFERENCES

1.KeysubstanceuseandmentalhealthindicatorsintheUnitedStates: Resultsfromthe2021NationalSurveyonDrugUseandHealth(HHS PublicationNo.PEP22-07-01-005,NSDUHSeriesH-57).Centerfor BehavioralHealthStatisticsandQuality,SubstanceAbuseandMental

HealthServicesAdministration.Availableat: https://www.samhsa.gov/ data/report/2021-nsduh-annual-national-report.PublishedDecember 2022.AccessedMarch13,2023.

2.SpencerMR,MininoAM,WarnerM.DrugoverdosedeathsintheUnited States,2001–2021.NCHSDataBrief,no457.Hyattsville,MD:National CenterforHealthStatistics.2022.Availableat: https://www.cdc.gov/ nchs/data/databriefs/db457.pdf.AccessedMarch13,2023.

3.U.S.opioiddispensingratemaps.CentersforDiseaseControland Prevention.Availableat: https://www.cdc.gov/drugoverdose/ rxrate-maps/index.html.PublishedNovember10,2021. AccessedMarch13,2023.

4.Annual2021ReportJeffersonCountyCoroner/MedicalExaminer’s Ofﬁce.Availableat: https://www.jccal.org/Sites/Jefferson_County/ Documents/Coroner_Medical%20Examiner%20Ofﬁce/2021% 20annual%20report.pdf.AccessedMarch13,2023.

5.HallGT,CruzDS,LankPM,etal.Opioid-relatedemergencydepartment visitsduringCOVID-19inalargehealthsystem. JAddictMed 2021;15(4):345–8.

6.LangabeerJR,StottsAL,BobrowBJ,etal.Prevalenceandchargesof opioid-relatedvisitstoU.S.emergencydepartments. DrugAlcohol Depend.2021;221:108568.

7.D’OnofrioG,O’ConnorPG,PantalonMV,etal.Emergencydepartmentinitiatedbuprenorphine/naloxonetreatmentforopioiddependence: arandomizedclinicaltrial. JAMA.2015;313(16):1636–44.

8.SordoL,BarrioG,BravoMJ,etal.Mortalityriskduringandafteropioid substitutiontreatment:systematicreviewandmeta-analysisofcohort studies. BMJ.2017;357:j1550.

9.WakemanSE,LarochelleMR,AmeliO,etal.Comparativeeffectiveness ofdifferenttreatmentpathwaysforopioidusedisorder. JAMANetw Open.2020;3(2):e1920622.

10.FairleyM,HumphreysK,JoyceVR,etal.Cost-effectivenessof treatmentsforopioidusedisorder. JAMAPsychiatry 2021;78(7):767–77.

11.ReuterQR,SantosAD,McKinnonJ,etal.Long-termtreatmentretention ofanemergencydepartmentinitiatedmedicationforopioidusedisorder program. AmJEmergMed.2022;55:98–102.

12.KaucherKA,CarusoEH,SungarG,etal.Evaluationofanemergency departmentbuprenorphineinductionandmedication-assistedtreatment referralprogram. AmJEmergMed.2020;38(2):300–4.

13.WalterLA,LiL,RodgersJB,etal.Developmentofanemergency department-basedinterventiontoexpandaccesstomedicationsfor opioidusedisorderinaMedicaidnonexpansionsetting:protocolfor engagementandcommunitycollaboration. JMIRResProtoc 2021;10(4):e18734.

14.MelnickER,NathB,DziuraJD,etal.Usercenteredclinicaldecision supporttoimplementinitiationofbuprenorphineforopioidusedisorder intheemergencydepartment:EMBEDpragmaticclusterrandomized controlledtrial. BMJ.2022;377:e069271.

15.LeT,CordialP,SankoeM,etal.Healthcareuseafterbuprenorphine prescriptioninacommunityemergencydepartment:acohortstudy. WestJEmergMed.2021;22(6):1270–5.

16.EdwardsFJ,WicelinskiR,GallagherN,etal.Treatingopioidwithdrawal withbuprenorphineinacommunityhospitalemergencydepartment:an outreachprogram. AnnEmergMed.2020;75(1):49–56.

17.OwensPL,WeissAJ,BarrettML.Hospitalburdenofopioid-related inpatientstays:metropolitanandruralhospitals,2016.2020May26. In:HealthcareCostandUtilizationProject(HCUP)StatisticalBriefs [Internet].Rockville(MD):AgencyforHealthcareResearchandQuality (US);2006Feb-.Table2,ICD-10-CMdiagnosiscodesdeﬁningopioidrelatedinpatientstays.Availableat: https://www.ncbi.nlm.nih.gov/ books/NBK559382/table/sb258.tab4/.AccessedMarch13,2023.

18.SASInstituteInc.2016.SAS® 9.4LanguageReference:Concepts, SixthEdition.Cary,NC:SASInstituteInc.

19.Racial/ethnicdifferencesinsubstanceuse,substanceusedisorders, andsubstanceusetreatmentutilizationamongpeopleaged12orolder (2015–2019)(PublicationNo.PEP21-07-01-001).Rockville,MD: CenterforBehavioralHealthStatisticsandQuality,SubstanceAbuse andMentalHealthServicesAdministration.Availableat: https://www. samhsa.gov/data/sites/default/ﬁles/reports/rpt35326/ 2021NSDUHSUChartbook.pdf.AccessedMarch13,2023.

20.Healthinsurancecoveragestatusandtypebygeography:2019and 2021.Availableat: https://www.census.gov/content/dam/Census/ library/publications/2022/acs/acsbr-013.pdf.AccessedMarch13,2023.

21.DeSousaT,AndrichikA,CuellarM,etal.The2022Annual HomelessnessAssessmentReport(AHAR)toCongress.Part1:PointIn-TimeEstimatesofHomelessness.TheU.S.DepartmentofHousing andUrbanDevelopmentOfﬁceofCommunityPlanningand Development.Availableat: https://www.huduser.gov/portal/sites/ default/ﬁles/pdf/2022-AHAR-Part-1.pdf.IssuedDecember2022. AccessedFebruary12,2023.

22.ChuaKP,DahlemCHY,NguyenTD,etal.Naloxoneandbuprenorphine prescribingfollowingUSemergencydepartmentvisitsforsuspected opioidoverdose:August2019toApril2021. AnnEmergMed 2022;79(3):225–36.

23.FosterSD,LeeK,EdwardsC,etal.Providingincentiveforemergency physicianX-waivertraining:anevaluationofprogramsuccessand postinterventionbuprenorphineprescribing. AnnEmergMed 2020;76(2):206–14.

24.KimHSandSamuelsEA.Overcomingbarrierstoprescribing buprenorphineintheemergencydepartment. JAMANetwOpen 2020;3(5):e204996.

25.MackeyK,VeazieS,AndersonJ,etal.Barriersandfacilitatorstotheuse ofmedicationsforopioidusedisorder:arapidreview. JGenInternMed 2020;35(Suppl3):954–63.

26.KajiAH,SchrigerD,GreenS.Lookingthroughtheretrospectoscope: reducingbiasinemergencymedicinechartreviewstudies. AnnEmerg Med.2014;64(3):292–8.

27.SoaresWE3rd,MelnickER,NathB,etal.Emergencydepartmentvisits fornonfatalopioidoverdoseduringtheCOVID-19pandemicacrosssix UShealthcaresystems. AnnEmergMed.2022;79(2):158–67.

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

AccessibilityofNaloxoneinPharmaciesRegistered UndertheIllinoisStandingOrder

P.QuincyMoore,MD*†

KaitlinEllis,MD‡

PatriciaSimmer,MD§

MweyaWaetjen,BA∥

EllenAlmirol,MPH,MA¶

ElizabethSalisbury-Afshar,MD,MPH#**

MaiT.Pho,MD,MPH††

*PermanenteMedicalGroup,Oakland,California

† KaiserPermanenteOaklandMedicalCenter,Departmentof EmergencyMedicine,Oakland,California

‡ BrownUniversity,DepartmentofObstetricsandGynecology, Providence,RhodeIsland

§ UniversityofChicago,DepartmentofMedicine,Chicago,Illinois

∥ UniversityofChicagoPritzker,SchoolofMedicine,Chicago,Illinois

¶ UniversityofChicago,ChicagoCenterforHIVElimination, Chicago,Illinois

# UniversityofWisconsin-Madison,SchoolofMedicineandPublic Health,DepartmentofFamilyMedicineandCommunityHealth, Madison,Wisconsin

**UniversityofWisconsin-Madison,SchoolofMedicineandPublic Health,DepartmentofPopulationHealthSciences,Madison,Wisconsin

†† UniversityofChicago,DepartmentofMedicine,SectionofInfectious DiseasesandGlobalHealth,Chicago,Illinois

SectionEditor:R.GentryWilkerson,MD

Submissionhistory:SubmittedMarch16,2023;RevisionreceivedJanuary24,2023;AcceptedFebruary9,2024

ElectronicallypublishedMay21,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_westjem

DOI: 10.5811/westjem.17979

Introduction: Toexpandaccesstonaloxone,thestateofIllinoisimplementedastandingorderallowing registeredpharmaciestodispensethedrugwithoutanindividualprescription.Toparticipateunderthe standingorder,pharmacieswererequiredtooptinthroughaformalregistrationprocess.Inourstudywe aimedtoevaluatetheavailabilityandpriceofnaloxoneatregisteredpharmacies.

Methods: Thiswasaprospective,de-identiﬁed,cross-sectionaltelephonesurvey.Trainedinterviewers posedaspotentialcustomersandusedastandardizedscripttodeterminetheavailabilityofnaloxone betweenFebruary–December,2019.Theprimaryoutcomewasdeﬁnedasapharmacyindicatingit carriednaloxone,currentlyhadnaloxoneinstock,andwasabletodispenseitwithoutan individualprescription.

Results: Of948registeredpharmacies,886(93.5%)weresuccessfullycontacted.Ofthose,792(83.4%) carriednaloxone,659(74.4%)hadnaloxoneinstock,and472(53.3%)allowedpurchasewithouta prescription.Naloxonenasalspray(86.4%)wastheformulationmostcommonlystocked.Chain pharmaciesweremorelikelytocarrynaloxone(adjustedoddsratio[aOR]3.16,95%conﬁdenceinterval [CI]1.97–5.01, P < 0.01)andhavenaloxoneinstock(aOR2.72,95%CI1.76–4.20, P < 0.01),butnomore likelytodispenseitwithoutaprescription.Pharmaciesinhigherpopulationareas(aOR0.99,95%CI 0.99–0.99, P < 0.05)andruralareasadjacenttometropolitanareas(aOR0.5,95%CI025–0.98, P < 0.05) werelesslikelytohavenaloxoneavailablewithoutaprescription.Associationsofnaloxoneavailability basedonotherurbanicitydesignations,overdosecount,andoverdoseratewerenotsigniﬁcant.

Conclusion: AmongpharmaciesinIllinoisthatformallyregisteredtodispensenaloxonewithouta prescription,theavailabilityofnaloxoneremainslimited.Additionalinterventionsmaybeneededto maximizethepotentialimpactofastatewidestandingorder.[WestJEmergMed.2025;26(1.1)71–78.]

INTRODUCTION

Theriseofopioid-relatedoverdosehashadadevastating effectoncommunitiesacrosstheUnitedStates.In2020alone, over68,000peoplediedfromopioid-relatedoverdose,ofwhich almost3,000occurredinthestateofIllinois.1,2 Therapidly evolvingdrugmarket,withtheintroductionoffentanyl, fentanylanalogues,andxylazineintotheillicitdrugsupply,has contributedtotheincreasingopioidoverdosefatalityrates, with64%ofUSdrugoverdosedeathsduringMay2020–April 2021involvingillicitlymanufacturedfentanyl.3–5

Inresponsetotheopioidoverdoseepidemic,amultiprongedapproachhasbeenenactedtoreducemorbidityand mortality.Amongtheseareseveralharmreduction strategies,includingsyringeserviceprograms,infectious diseasescreening,drugchecking(eg,fentanyltest-strip distribution),supervisedconsumptionsites,anddistribution ofnaloxone.Multiplestudieshavedemonstratednaloxone’ s abilitytobeusedeffectivelyandappropriatelybypeople withnoformalmedicaltraining.6 Forexample,Enteenetal foundthatofthe24%ofpatientswhoreturnedfornaloxone reﬁllsoverasix-yearperiod,11%ofthosereportedusing naloxoneduringanoverdoseevent,withan89%successrate ofoverdosereversal.7 Further,studieshaveshownthat naloxonedistributiondoesnotleadtoincreasedopioid consumptionandmayevenleadtodecreaseduse.7,8 Recognizingitssafetyandefﬁcacy,theUSSurgeonGeneral issuedanadvisorynoticein2018encouragingitsuseand availability.9 Despitewidespreadsupportbyleading healthcareorganizationsandfederalagencies,naloxone accessremainslimited,andopportunitiestohelpindividuals atriskforoverdosearefrequentlymissed.10,11

Asof2017,all50stateshadpassedlegislationexpanding publicaccesstonaloxone.12 Inadditiontolegislation protectingagainstcivil,criminal,orprofessionalliabilityfor bothprescribersandlayadministratorsofnaloxone,some stateshaveintroducedpoliciestoincreasetheaccessibilityof thelife-savingdrug.Studieshavedemonstratedthat pharmacistsarewillingtoprovidenaloxonetothepublic underastandingorderorothersimilarprocess(Stewartetal, 2018;Nielsenetal,2016;Greenetal,2017).Toexpand accesstonaloxone,theIllinoisDepartmentofPublicHealth (IDPH)implementedastatewidestandingorderin2017 (PublicAct99–0480),allowingregisteredpharmaciesto distributenaloxonetopatientswithoutanindividual prescriptionintheirname.ToregisterundertheIllinois NaloxoneStandingOrder,licensedpharmaciesmust participateinapre-approvedtrainingandagreetoreport anydispensednaloxonetotheIllinoisPrescription MonitoringProgram.13

Illinoisisnowoneof49statesthatallowpharmaciststo dispensenaloxonewithoutapatient-speciﬁcprescription fromaclinician,44ofwhichuseastandingorder.14 Despite this,studiesfromotherstateshaveshownlimiteduptakeof

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthisissue?

Moststatesoffernaloxoneatpharmacies withoutaprescription,butuptakeislimited.

Whatwastheresearchquestion?

Whichpharmaciesregisteredunderthe IllinoisNaloxoneStandingOrder hadnaloxoneavailablewithout aprescription?

Whatwasthemajor ﬁndingofthestudy?

Only53.3%ofregisteredpharmacies(1/8 th of allIllinoispharmacies)hadnaloxoneinstock andavailablewithoutaprescription.

Howdoesthisimprovepopulationhealth?

Statewidestandingordersareanimportant butinsuf ﬁ cientsteptowardwidespread naloxonepossession.Moreeffortisneededto improveparticipation.

thesenewprotocolsandwidevariationsinavailabilityof naloxoneatregisteredpharmacies.15–22 Inthiscrosssectionalstudyweaimedtoevaluatetheaccessibilityof naloxoneatpharmaciesregisteredunderthestatewide standingorderbydeterminingwhichpharmaciesreported routinelycarryingnaloxone,whichpharmacieshad naloxonecurrentlyinstock,whichpharmacieswerewilling todispensenaloxonewithoutaprescription,which formulationswerecarried,andtheout-of-pocketcostof naloxone.Ourprimaryoutcomewastodeterminewhich pharmacieshadnaloxoneavailablewithoutaprescriptionon thedayoftheinquiry.Wefurthercomparedpharmacies’ naloxoneavailabilitybypharmacytype(chainvsnon-chain), urbanicity,populationofZIPCode,andopioidoverdose ratesinthepharmacies’ surroundingregion.Thisstudy expandsontheexistingliteraturebyusingasamplethat includedallpharmaciesthatoptedintoregisteringunderthe IllinoisNaloxoneStandingOrder.Wealsoanalyzedfactors thatmayaffectthelikelihoodthatapharmacyhadnaloxone availablewithoutaprescription,whichwasrarelydonein previousstudies.

METHODS StudyDesign

Aprospective,anonymous,cross-sectional “secretshopper” telephonesurveysamplingallIllinoispharmacies

thathadregisteredunderthestate-levelstandingorderwas performedbysixtrainedcallers.Thelistofpharmacies registeredunderthestandingorderwasaccessedon February17,2019(Chicago)andMay23,2019(remainder ofIllinois)viatheIDPHOpioidDataDashboard.2 Thelist ofpharmacies,theircities,andtheircontactnumberswere transposedfromthedashboardintoanExceldocument (MicrosoftCorp,Redmond,WA)fortrackingpurposes.For eachpharmacy,weobtainedaZIPCodeandevidenceof continuedoperationviaGooglesearches.Ifapharmacywas foundtonolongerbeinexistence,thepharmacywasmarked asunabletocontact.

DataCollection

Sixstudypersonnel(oneattendingphysician,oneresident physician,threemedicalstudents,andonemaster’slevel researchassociate)underwentthreehoursoftraining consistingofreviewingthecallscript,discussingthelogic behindeachquestion,discussingspeciﬁclanguagetouse,and conductingatleastthreepilotcallstopharmaciesnot includedinthestudysample.Pilotcallsweredebriefedas agroup.

Thecallersposedaspotentialcustomersanduseda standardizedscripttoasktargetedquestions.Callers followedautomatedpromptsorrequestedtobeconnectedto thepharmacy.Callersspokewithwhicheverpharmacystaff ﬁrstansweredthecallandcontinuedtousethescriptifthe callwastransferredtootherpharmacystaff.Ifplacedon hold,thecallerwaitedupto10minutesbeforeterminating thecall.Ifthecallwasinterruptedorthepharmacywas unreachableontheinitialattempt,thepharmacywas contacteduptotwoadditionaltimes.Ifapharmacywas unreachablethreetimes,itwasconsideredinactiveandnot includedinouranalyses.Callswerecompletedfrom February–December2019.Datawascollectedeitherdirectly intoREDCap9.5.35LTS(ResearchDataCapturehostedat UniversityofChicagoMedicine)orintoMicrosoftExceland latertransposedintoREDCap.

Thescriptforthecallswascreatedusinganiterative processbythegroupofinvestigators.Wedesignedthescript toaddressthestudyquestionswhilemaintainingthe appearanceofalaycaller.Thegenericnameofthe medication(naloxone)wasusedinitially.Ifstaffseemed uncertainofthemedicationinquestion,thebrandnameof Narcanwasusedafter ﬁrstrepeatingthegenericname.See Appendix1forthescriptforthesecret-shoppertelephone surveyofpharmaciesthatareregisteredundertheIllinois NaloxoneStandingOrder.

Measures

Wecollectedcharacteristicsforeachpharmacybasedon pharmacytype,urbanicity,populationofpharmacyZIP Code,andtheoverdoserateinthepharmacyZIPCode. Pharmacieswereclassiﬁedas “chain” iftheyhadfouror

morelocationsundersharedownership,and “non-chain” if theyhadfewerthanfourlocations.15,16 Wedeﬁned urbanicityusingtheUSDepartmentofAgriculture2013 Rural-UrbanContinuumCodes(RUCC)thatassign countiesascoreonascaleof1-9basedoncountypopulation sizeandadjacencytoametropolitanarea.17 Ascommonly practicedelsewhereintheliterature,wedividedthis continuumintothreegroups:1)urban;2)ruraladjacenttoa metropolitanarea;and3)ruralandnonadjacenttoa metropolitanarea.

WeusedZIPCodescorrespondingtoeachpharmacyto analyzethedatausingoverdoseratesandpopulation. Numberofcombinedfatalandnon-fatalopioid-related overdoseeventsin2018byZIPCodewasobtainedfromthe IDPHOpioidDashboard.2 WeobtainedpopulationbyZIP Codefor2018fromtheUSCensusBureau.18 Usingthe populationsizeandthenumberofoverdoses,wecalculateda 2018rateofcombinedfatalandnon-fatalopioid-related overdoseper10,000peopleforeachZIPCodeinoursample.

StatisticalAnalyses

Weperformedbivariateanalysestodeterminewhether differencesinnaloxoneavailabilityonthedayofthecallwere signiﬁcantlydifferentbasedonthefollowingcovariates: pharmacytype;urbanicityusingRUCCcode;populationof pharmacyZIPCode;andthe2018overdosecountand overdoserateper10,000residentsinthepharmacyZIP Code.WeanalyzeddatausingSTATAMPv17statistical softwarerelease15(StataCorp,LLC,CollegeStation,TX). ThisstudywasreviewedbytheUniversityofChicago InvestigationalReviewBoardanddeterminedtobeexempt fromreview.

RESULTS

Weidentiﬁed948pharmaciesregisteredundertheIllinois NaloxoneStandingOrderandsuccessfullycontacted886 (93.5%)(Figure1).Ofthe886pharmaciesthatwere successfullycontacted,806(91.0%)werechainpharmacies and80(9.0%)werenon-chain.Ofthe886contacted pharmacies,807(91.1%)werelocatedinurbanZIPCodes, 57(6.4%)inruralZIPCodesadjacenttoametropolitanarea, and22(2.5%)inruralZIPCodesthatwerenonadjacenttoa metropolitanarea.Additionally,ofthecontacted pharmacies,792(89.4%)reportedcarryingnaloxone,with 659(74.4%)reportingthemedicationtobeinstockatthe timeofthecall,and472(53.3%)respondingthatthecaller didnotneedaprescriptionfromadoctortopurchasethe naloxone.The472pharmacies(53.3%)thatcarried naloxone,hadnaloxoneinstock,andofferednaloxone withoutrequiringaprescriptionwereconsideredpositivefor theprimaryoutcome.Pharmacycharacteristicsare summarizedin Table1

Figure2 displaysthecascadeofnaloxoneavailabilityby pharmacytypeandRUCC.PharmaciesinurbanRUCC

Figure1. AvailabilityofnaloxoneandneedforaprescriptioninIllinoispharmaciesregisteredundertheIllinoisNaloxoneStandingOrder.

Table1. Pharmacytype,urbanicity,andnaloxoneavailabilityofpharmaciesregisteredundertheIllinoisNaloxoneStandingOrderthatwere successfullycontacted(n = 886).

Successfully contacted, n = 886(Col%)

Carry Naloxone n = 792(Row%)

CarryNaloxone, instock n = 659(Row%)

Naloxoneavailable withoutaRx, n = 472(Row%)

Pharmacytype

Chain(CVS,Walgreens)806(91.0%)728(90.3%)611(83.9%)432(70.7%)

Non-chain(Independent)80(9.0%)64(80.0%)48(75.0%)40(83.3%)

RUCC

Urban807(91.1%)720(89.2%)599(83.2%)433(72.2%)

Ruraladjacenttoa metropolitanarea

57(6.4%)52(91.2%)43(82.7%)28(65.1%)

Ruralandnonadjacenttoa metropolitanarea 22(2.5%)20(90.9%)17(85.0%)11(64.7%)

Rx,prescription; RUCC,Rural-UrbanContinuumCodes.

codeshadthehighestnaloxoneavailabilitywithouta prescription(63.7%).Alargerproportionofchain pharmaciescarriednaloxone(90.3%)comparedtononchainpharmacies(80.0%)(P < 0.01).Ofthe772pharmacies thatstockednaloxoneandprovidedaresponsetothetypeof naloxone,624(78.8%)carriednaloxonenasalspray (see Table2).

Intheadjustedanalyses,wefoundthatchainpharmacies hadgreateroddsofcarryingnaloxone(adjustedoddsratio [aOR]3.16,95%conﬁdenceinterval[CI]1.97–5.01, P < 0.01) andhavingnaloxoneinstock(aOR2.72,95%CI1.76–4.20,

P < 0.01)comparedtonon-chainpharmacies(Table3). However,therewerenodifferencesbetweenpharmacytype andnaloxoneavailabilitywithoutaprescription.With regardtoRUCC,ruraladjacenttoametroareahadlower oddscomparedtourbanareasofprovidingnaloxone withoutaprescription(aOR0.50,95%CI0.25–0.98, P = 0.05).WealsoobservedthatmoredenselypopulatedZIP Codeswerelesslikelytohavenaloxoneavailablewithouta prescription(aOR0.99,0.99–0.99, P < 0.01).Neither overdose(OD)countnorODratewereassociatedwith naloxoneavailability.

Figure2. Pharmacytype,countyurbanicity,andnaloxoneavailabilityofpharmaciesregisteredundertheIllinoisNaloxoneStandingOrder thatweresuccessfullycontacted. Rx,prescription.

Table2. Ofthosewhocarrynaloxone,availableformulationsof naloxoneandmedianprice.

Naloxone types N = 722 (%) Medianprice [IQR]

Naloxone nasalspray

624(86.4)$135.99[$89.99,$4,500]

IMvials71(9.8)$39.50[$21.99.$239.00]

Naloxone autoinjector

27(3.8)$4,000[$399.59,$6,000.00]

IQR,interquartilerange; IM,intramuscular.

DISCUSSION

Standingordersareanimportantsteptowardreducing opioid-relatedmortality,butour ﬁndingssuggestthis legislationhasnothadthedesiredeffectinstateresidents’ accesstonaloxone.In2019,twoyearsafterthe implementationoftheorder,therewasanaverageof3,861 licensedpharmaciesstatewide.19 Ofthese,only948(24.6%)

wereregisteredunderthestandingorderatthetimeofour study.Wesuccessfullycontacted91%oftheregistered pharmaciesandfoundthatjustoverhalf(53.3%)had naloxoneavailableonthedayofcontactandappropriately offereditwithoutrequiringaprescription.Giventhatall pharmaciesonourcontactlistunderwentpre-approved trainingtoregisterwithIDPHasanaloxonedistributionsite underthestandingorder,our ﬁndingsindicatethereis substantialroomforimprovement.

Studiesfromotherstateswithcomparablestatewide naloxoneaccesspolicieshaveshownlimiteduptakewith widevariationsinavailabilityofnaloxone.Across California,Texas,Pennsylvania,Massachusetts,andNew York,theproportionofpharmaciesthathadnaloxonein stockrangedfrom23.5–70%,withsomevariationbasedon stateandthespeciﬁcsampleofpharmaciesstudied.20–24 Few studieshaveanalyzedspeciﬁccharacteristicsthatmayaffect anindividualpharmacy’slikelihoodofhavingnaloxone available.22,25 InPennsylvania,Gravesetalfoundthatchain

Table3. Associationbetweenpredictorsandcarrynaloxone,instock,andnoprescriptionneeded.

Pharmacytype

Non-chain RefRefRef

Chain 3.16(1.97,5.01) <0.012.72(1.76,4.20) <0.01 0.45(0.20,1.00)0.05

RUCC

Urban RefRefRef

Ruraladjacenttoametroarea1.77(0.79,3.98)0.171.27(0.69,2.36)0.44

0.50(0.25,0.98)0.05

Rural,nonadjacenttoametroarea1.16(0.41,3.30)0.781.15(0.47,2.82)0.750.48(0.17,1.36)0.17

PopulationbyZIPCode1.00(0.99,1.00)0.611.00(0.99,1.00)0.40

0.99(0.99,0.99)0.003

ODcount1.00(0.99,1.00)0.741.00(0.99,1.00)0.420.99(0.98,1.00)0.09

ODrate0.99(0.98,1.00)0.160.99(0.99,1.00)0.360.99(0.98,1.00)0.27

Bold, P ≤ 0.05;Adjustedanalysesincludecontrollingforpharmacytype,RUCC,andpopulationbyZIPCode. Rx,prescription; aOR,adjustedoddsratio; CI, conﬁdenceinterval; RUCC,Rural-UrbanContinuumCodes; OD,overdose.

pharmaciesweremorelikelytocarrynaloxone,butODrate andurbanicitydidnotinﬂuencenaloxoneavailability.22 In Indiana,Meyersonetalfoundthatchainpharmacies, pharmacieswithmorethanonefull-timepharmacist,and thosewherepharmacistshadreceivednaloxone-related continuingeducationwereassociatedwithincreased likelihoodofstockingnaloxone.25

Asystematicreviewofthetopicfoundthata heterogeneousgroupof30studieshadwide-ranging ﬁndings, butoverallone-thirdofpharmaciesauditeddidnotcarry naloxoneandalmosthalfdidnotoffernaloxonewithouta prescription.26 Whilepreviousstudieshaveexploredthe availabilityofnaloxoneunderastandingorderindifferent states,analysisoffactorsthatmaycontributetothe likelihoodthatapharmacyhasnaloxoneavailablewithouta prescriptionremainslimited.Ourstudyisalsouniqueforits highresponserateaswellasouruseofasampleincludingall pharmaciesthatoptedintoformalizedtrainingand registrationunderthestandingorder.

Improvedaccesstonaloxonethroughcommunity pharmaciesmaycomethroughmultipleapproaches.First, withlessthanaquarterofpharmaciesregistered,our findings highlighttheneedformorewidespreadparticipationinthe IllinoisNaloxoneStandingOrder.Itappearsthatthepublic goodandthe financialincentivesattachedtoincreased dispensingofnaloxoneareinsufficienttoincentivize pharmaciestotakethestepsnecessarytoregisterunderthe standingorder.Ofnote,IllinoisMedicaidplansarerequired tocoveratleastoneformulationofnaloxone,withthe intranasalformulationthemostcommonlycovered formulation.IllinoisMedicaiddoesnotchargeacopayfor receiptofnaloxone.Additionalincentivesmaybenecessary tomobilizegreaterpharmacyparticipationstatewide.

Ruralareasappearedtohaveparticularlypooraccessto naloxonethroughcommunitypharmacies.While11.5%of Illinoisresidentsliveinruralareas,wefoundthatonly22 (2.3%)ofthepharmaciesregisteredunderthestandingorder wereinruralareas.27 Whiletherewasnosigniﬁcant differenceintheprimaryoutcomeinruralvsurban pharmacies,theoverallpaucityofregisteredpharmaciesin ruralareashighlightsalackofaccessthatmayputrural peoplewhousedrugsathigherriskofdeathfromoverdose. Thismayfurtherexacerbatethedisproportionateimpactof theopioidcrisisonruralareas.28,29

Oftheregisteredpharmacieswecontacted,our ﬁndings highlightspeciﬁctrendsthatmayinformeffortstoimprove accesstonaloxone.Wefoundthatchainpharmacieswere morelikelythannon-chainpharmaciestocarrynaloxone andhaveitinstockbutwerenomorelikelytohaveitinstock withoutaprescriptionrequired.Thissuggeststhatthereare policiesuniquetochainpharmaciesthatfacilitateregistering underthestandingorderandstockingnaloxone,butthat perhapstrainingforcustomer-facingstaffhasbeen inadequate.Thisledultimatelytosimilaroutcomestonon-

chainpharmacieswhenitcametocustomersseekingto purchasenaloxonewithoutaprescription.These ﬁndings havesomeconsistencywithonePennsylvaniastudy,which foundchainpharmaciestobemorelikelytocarrynaloxone andanswerquestionscorrectlyaboutthestandingorderfor naloxone.22 Chainpharmaciesmayhavemorestandardized trainingprogramsforcertainstaffmembers,maintain robustsupplychainsfornaloxone,orhaveastronger responsetopublicpressuretocontributetoreducingopioidrelateddeaths.

Therewasnostatisticallysigniﬁcantassociationbetween thenumberorrateofODsinaZIPCodeandlikelihoodof naloxoneavailability.This ﬁndingsuggeststhattheremaybe additionaloutreachorincentivesnecessarytoencourage pharmaciesinareaswiththehighestratesofODtoincrease accesstonaloxoneviathestandingorder.

Costandavailableformulationmayhaveasignificant impactonhowlikelyacustomeristoobtainnaloxone.Inour sample,bothcostandformulationwerevariable.The majorityofpharmaciesthathadnaloxoneinstockcarried thenasalnaloxonespray(brandnameNarcan)foran averagecostof$135.99foratwo-pack.WhileIllinois Medicaidplanscoveratleastoneformulationofnaloxone withoutcopay,privateinsuranceandMedicarePartDplans havevariablecopaystructuresandformulationcoverage. Foruninsuredindividuals,thosewhodon’twanttousetheir insuranceto fillthismedication,orthoseforwhomnaloxone isnotacoveredmedication,theout-of-pocketcostmaybea significantdeterrenttoobtainingnaloxone.Vialsof naloxone,whichcanbeusedwithaneedleandsyringeand injectedintramuscularly,orwithanatomizerfornasal administration,hadalowermedianpriceof$39.50;however, only9%ofpharmacieshadthisformulationinstock,andthe availabilityandcostofothernecessarysuppliessuchas syringes,intramuscularneedles,and/ornasalatomizerswas unclear.Wedobelievethatsomeofthehighpricesthatwere reportedbypharmacystaffareinaccurateandforthisreason wepresentthemedianprice,whichwebelieveaccurately reflectswhatmostconsumerswouldpayoutofpocket. Ourstudyhighlightstheneedforadditionalstrategiesto maximizeaccesstonaloxone.Giventhatruralareasareless likelytohavecommunity-basednaloxonedistribution(often aserviceofferedatharmreduction/syringeservice programs),thisneedisparticularlygreatinruralareas.30–32 Futureresearchisneededtounderstandwhethernaloxone availabilityinpharmaciesisassociatedwithincreased utilizationand,ifso,howtoincreaseavailabilityofnaloxone viastandingorderinretailpharmacies.Possible considerationscouldincludethefollowing:publiceducation campaignsthatwouldworktoincreasedemandfornaloxone inpharmacies,therebyencouragingpharmaciestoregister andstocknaloxone;offering financialincentivesorother publicrecognitionforpharmaciesthatregisterforthe standingorderandstocknaloxoneformulations;and

improvedpublichealthoutreachandeducationalprograms (eg,academicdetailing)toincreaseawarenessamong pharmacies,pharmacists,andpharmacystaffaboutthe purposeofandevidencebaseofnaloxoneasitrelatesto reducingopioid-relatedmortalityatthecommunitylevel.

Researchhasfoundthatpharmacists’ discomfort dispensingnaloxonetocustomersremainsanimportant barrierandoftenresultsfrominadequatetraining(Green, 2017;Thornton,2017;Rudolph,2018).AsofNovember20, 2017,only19stateshadmandatednaloxoneeducationfor pharmacists(Roberts,2019).33 Illinoisregulationrequires participatingpharmaciststocompleteanIllinois DepartmentofHumanServices-approvedtrainingmodule orto “understandtheNaloxoneStandardizedProcedures” andwatchtwotrainingvideos(IDPHNaloxoneFAQ),butit isunclearhowmuchofthistrainingispassedalongtostaff whodirectlyinteractwithcustomers.Onestudycomparing trainingmaterialprovidedbystatesfoundthatwhilemost materialcoveredthepurposeanduseofnaloxoneaswellas thestandingorderlegislation,fewprovidedthorough educationonhowtocommunicatethisinformationto customers(Carpenter,2018).Overall,whiletherehasbeen anincreaseinnaloxonedispensedacrossallstateswith expandedaccesspolicies,retailpharmacynaloxone distributionisstillunderusedandvariesstateby state(Xu,2018).

LIMITATIONS

Ourstudyhasseverallimitations.Wedidnotclarifythe roleofthestaffmemberwithwhomwewerespeaking.Itis possiblethatifwehadaskedtospeakdirectlytothe pharmacist,wewouldhaveobtainedmoreaccurate information;however,wefeltitwasmostusefultomimica morenaturalconsumerinteraction.Itispossible,however, thatresponseswouldvarybetweenstaffmembersatan individualpharmacy.Informationmayalsohavebeenmore accuratehadweidentiﬁedourselvesasacademicresearch staff.Fiveofsixcallershadatleastsomemedical background,butwebelievethatotherstudiescouldachieve thesamegoalinananalogousstudyusingstaffwithno medicalbackground.

Wedidnotcallpharmaciesthatwerenotlistedonthe IDPHwebsite;sofutureresearchmayincludeanalysisofthe percentageoftotalpharmaciesindifferentregionsthatoffer naloxone.Wecollectedonlyinformationaboutout-ofpocketcost,whichislikelyonlyrelevanttopatientswithout insurance,thosewhodon’twanttouseinsurancewhen receivingnaloxone,orthosewithoutnaloxoneincludedin theirpharmacybeneﬁt.Lastly,andperhapsmostrelevantto futureresearch,werecognizethatavailabilityofnaloxonein retailpharmaciesmaynotdirectlycorrelatewithincreased utilizationbypeoplewhousedrugs(PWUD).Futurestudies shouldincorporateinputfromPWUDtodelineate preferencesinsourcesofnaloxone.

CONCLUSION

Wefoundthattwoyearsafterimplementationofthe IllinoisNaloxoneStandingOrder,onlyone-eighthofall pharmacieshadnaloxoneinstockandavailablewithouta prescription.Withinthisgroup,chainpharmaciesweremore likelytocarrynaloxoneandhaveitinstockbutwerenomore likelytoprovideitwithoutaprescription.Pharmaciesin moredenselypopulatedZIPCodesandthosewithaRuralUrbanContinuumCodereﬂectingruralareasthatare adjacenttometroareaswerelesslikelytohavenaloxone availablewithoutaprescription.Overdoseratesinthe surroundingcommunityhadnoeffectonnaloxone availability.Ourstudyillustratesauniquesampleofall pharmaciesstatewidethathavegonethroughformaltraining andregistrationunderthestandingorder.

Increasedaccesstonaloxoneinretailpharmaciesin Illinoiswillrequireimprovedeffortsrelatedtoawarenessand implementationofthestandingorder,aswellasfurther investigationintothereasonsthatapharmacythathasgone throughtheprocessofapplyingtobeabletousethestanding orderdoesnotreliablystocknaloxoneandmakeitavailable withoutprescription.Speciﬁcattentionshouldbe giventoareaswherethereislimitedaccesstonaloxone throughcommunity-baseddispensingprograms andwhereratesofoverdoseandpotentialforimpact arehighest.

AddressforCorrespondence:P.QuincyMoore,KaiserPermanente OaklandMedicalCenter,DepartmentofEmergencyMedicine,3600 Broadway,Oakland,CA94611.Email: paul.q.moore@kp.org

ConflictsofInterest:Bythe WestJEMarticlesubmissionagreement, allauthorsarerequiredtodiscloseallaffiliations,fundingsources and financialormanagementrelationshipsthatcouldbeperceived aspotentialsourcesofbias.Noauthorhasprofessionalor financial relationshipswithanycompaniesthatarerelevanttothisstudy. Therearenoconflictsofinterestorsourcesoffundingtodeclare.

REFERENCES

1.NationalInstituteonDrugAbuse.Drugoverdosedeathrates.2023. Availableat: https://nida.nih.gov/research-topics/trends-statistics/ overdose-death-rates.AccessedJanuary19,2022.

2.IllinoisDepartmentofPublicHealth.IDPHdata.Availableat: https://dph. illinois.gov/topics-services/opioids/idph-data-dashboard.html AccessedJanuary19,2022.

3.O’DonnellJ,TanzLJ,GladdenRM,etal.Trendsinandcharacteristicsof drugoverdosedeathsinvolvingillicitlymanufacturedfentanyls-United States,2019–2020. MorbMortalWklyRep.2021;70(50):1740–6.

4.KariisaM,PatelP,SmithH,etal.Notesfromthe ﬁeld:xylazinedetection andinvolvementindrugoverdosedeaths-UnitedStates,2019. MorbMortalWklyRep.2021;70(37):1300–2.

5.ChhabraN,MirM,HuaMJ,etal.Notesfromthe ﬁeld:xylazine-related deaths-CookCounty,Illinois,2017–2021. MorbMortalWklyRep 2022;71(13):503–4.

6.WalleyAY,XuanZ,HackmanHH,etal.Opioidoverdoseratesand implementationofoverdoseeducationandnasalnaloxonedistribution inMassachusetts:interruptedtimeseriesanalysis. BMJ 2013;346:f174.

7.EnteenL,BauerJ,McLeanR,etal.Overdosepreventionandnaloxone prescriptionforopioidusersinSanFrancisco. JUrbanHealth. 2010;87(6):931–41.

8.BazaziAR,ZallerND,FuJJ,etal.Preventingopiateoverdosedeaths: examiningobjectionstotake-homenaloxone. JHealthCarePoor Underserved.2010;21(4):1108–13.

9.OfﬁceoftheSurgeonGeneral.U.S.SurgeonGeneral’sAdvisoryon NaloxoneandOpioidOverdose.2018.Availableat: https://www.hhs. gov/surgeongeneral/priorities/opioids-and-addiction/naloxoneadvisory/index.html.AccessedJanuary1,2020.

10.GuyGPJr.,HaegrichTM,EvansME,etal.Vitalsigns:pharmacy-based naloxonedispensing UnitedStates,2012–2018. MorbMortalWkly Rep.2019;68(31):679–86.

11.FollmanS,AroraVM,LyttleC,etal.Naloxoneprescriptionsamong commerciallyinsuredindividualsathighriskofopioidoverdose. JAMA NetwOpen.2019;2(5):e193209.

12.TheNetworkforPublicHealthLaw.Legalinterventionstoreduce overdosemortality:naloxoneaccesslaws.2021.Availableat: https:// www.networkforphl.org/wp-content/uploads/2021/05/NAL-Final-4-29. pdf.AccessedJune7,2022.

13.IllinoisDepartmentofPublicHealth.IDPH-NaloxoneStandingOrder Form.Availableat: https://idph.illinois.gov/Naloxone/ AccessedJune7,2022.

14.PrescriptionDrugAbusePolicySystem(PDAPS).Availableat: http:// www.pdaps.org/datasets/laws-regulating-administration-ofnaloxone-1501695139.AccessedJune7,2022.

15.SchommerJC.APhAcareerpathwayevaluationprogramforpharmacy professionals2012.2013.Availableat: https://aphanet.pharmacist. com/sites/default/files/files/Profile_06%20Chain%20pharmacy% 20Final%20071713.pdf.AccessedJanuary19,2022.

16.HatemiPandZornC.IndependentpharmaciesintheU.S.aremoreon therisethanonthedecline.2020.Availableat: https://www.pcmanet. org/wp-content/uploads/2020/03/FINAL_Independent-Pharmaciesin-the-U.S.-are-More-on-the-Rise-than-on-the-Decline.pdf AccessedJanuary19,2022.

17.U.S.DepartmentofAgricultureEconomicResearchService.RuralUrbanContinuumCodes.2020.Availableat: https://www.ers.usda.gov/ data-products/rural-urban-continuum-codes/documentation/ AccessedJanuary19,2022.

18.U.S.CensusBureau.Availableat: https://www.census.gov/ AccessedJune7,2022.

19.SmithSteven.IllinoisDepartmentofFinancialandProfessional Regulation.PublishedonlineFebruary1,2023.

20.PuzantianTandGasperJJ.Provisionofnaloxonewithoutaprescription byCaliforniapharmacists2yearsafterlegislationimplementation. JAMA.2018;320(18):1933–4.

21.EvoyKE,HillLG,GroffL,etal.Naloxoneaccessibilitywithouta prescriberencounterunderstandingordersatcommunitypharmacy chainsinTexas. JAMA.2018;320(18):1934–7.

22.GravesRL,AndreyevaE,PerroneJ,etal.Naloxoneavailabilityand pharmacystaffknowledgeofstandingorderfornaloxonein Pennsylvaniapharmacies. JAddictMed.2019;14(4):272–8.

23.StopkaTJ,DonahueA,HutchesonM,etal.Non-prescriptionnaloxone andsyringesalesinthemidstofopioidoverdoseandhepatitis Cvirusepidemics:Massachusetts,2015. JAmPharmAssoc(2003) 2017;57(2S):S34–44.

24.CorrealA.Overdoseantidoteissupposedtobeeasytoget.It’sNot. 2018.Availableat: https://www.nytimes.com/2018/04/12/nyregion/ overdose-antidote-naloxone-investigation-hard-to-buy.html AccessedJanuary1,2020.

25.MeyersonBE,AgleyJD,DavisA,etal.Predictingpharmacynaloxone stockinganddispensingfollowingastatewidestandingorder,Indiana 2016. DrugandAlcoholDependence.2018;188:187–92.

26.LaiRK,FriedsonKE,RevelesKR,etal.Naloxoneaccessibilitywithout anoutsideprescriptionfromU.S.communitypharmacies:asystematic review. JAmPharmAssoc(2003).2022;62(6):1725–40.

27.U.S.CensusBureau.2010CensusofPopulationandHousing, PopulationandHousingUnitCounts,CPH-2-15.2012.Availableat: https://www2.census.gov/library/publications/decennial/2010/cph-2/ cph-2-15.pdf.AccessedFebruary2,2023.

28.JenkinsRA,WhitneyBM,NanceRM,etal.TheRuralOpioidInitiative Consortiumdescription:providingevidencetounderstandthefourth waveoftheopioidcrisis. AddictSciClinPract.2022;17(1):38.

29.BergoCJ,EpsteinJR,HoferkaS,etal.AVulnerabilityassessmentfora futureHIVoutbreakassociatedwithinjectiondruguseinIllinois, 2017–2018. FrontSociol.2021;6:652672.

30.WhiteHouseOfficeofNationalDrugControlPolicy(ONDCP).Vermont DrugControlUpdate.Availableat: https://obamawhitehouse.archives. gov/sites/default/files/docs/state_profile_-_vermont_0.pdf AccessedJune7,2022.

31.BuerLesly-Marie. RXAppalachia:StoriesofTreatmentandSurvivalin RuralKentucky.Chicago,IL:HaymarketBooks;2020.

32.OstrachB,BuerLM,ArmbrusterS,etal.COVID-19andruralharm reductionchallengesintheUSsouthernmountains. JRuralHealth 2021;37(1):252–5.

33.LegislativeAnalysisandPublicPolicyAssociation.NaloxoneAccess: SummaryofStateLaws.2020.Availableat: https://legislativeanalysis. org/wp-content/uploads/2020/10/Naloxone-summary-of-state-lawsFINAL-9.25.2020.pdf.AccessedFebruary3,2023.

Special Issue on Substance Misuse and Addiction Disorders

Penn State Health Emergency Medicine

About Us:

Western Journal of Emergency Medicine: Integrating

Co-Guest Editors

Western Journal of Emergency :

Western Journal of Emergency Medicine:

Editorial Board

Board

Editorial Board

Advisory Board

Advisory Board

Editorial Staff

Western Journal of Emergency Medicine:

JOURNAL FOCUS

Table of Contents

Table of Contents

Western Journal of Emergency Medicine:

Western Journal of Emergency Medicine:

Substance Use and Addiction Disorders : A Call for Increased Screening and Treatment in the Emergency Department

REFERENCES

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

ImplementationandEvaluationofaBystander NaloxoneTrainingCourse

INTRODUCTION

METHODS

Curriculum

CourseEvaluation

StatisticalAnalysis

RESULTS

DISCUSSION

LIMITATIONS

CONCLUSION

REFERENCES

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

HarmReductionintheField:FirstResponders’ Perceptions ofOpioidOverdoseInterventions

INTRODUCTION

METHODS

StudyDesignandSetting

TheoreticalFramework

ReﬂexivityandPartnership

ParticipantRecruitment

DataCollection

ThematicAnalysis

RESULTS

ParticipantDemographics

QualitativeResults

Leave-behindNaloxone

HIVandHepatitisCVirusTesting

Facilitators

DISCUSSION

LIMITATIONS

CONCLUSION

REFERENCES

SUBSTANCE USE DISORDER:ORIGINAL RESEARCH

PragmaticEmergencyDepartmentInterventionReducingDefault QuantityofOpioidTabletsPrescribed

INTRODUCTION

METHODS

Intervention

Participants

Outcomes

Analysis

RESULTS

DISCUSSION

LIMITATIONS

CONCLUSION

REFERENCES

REVIEW:SUBSTANCE USE DISORDER

BystandersSavingLiveswithNaloxone:AScopingReviewon MethodstoEstimateOverdoseReversals

INTRODUCTION

METHODS

DataExtractionandSynthesis

RESULTS

StudyCharacteristics

MathematicalModels

Meta-analysis

SpatialAnalysis

DISCUSSION

OpioidEducationandNaloxoneDistributionPrograms

LIMITATIONS

CONCLUSION