Emergency departments (EDs) are critical settings for treating opioid use disorder, but few ED physicians initiate treatments like administration of buprenorphine, a drug known to activate the brain's opioid receptors and help patients safely manage and treat opioid addiction. However, emergency department physicians are more likely to start prescribing buprenorphine if they see their colleagues prescribe it, a new Yale study reveals.
The findings, published Nov. 10 in JAMA Network Open, highlight strategies for boosting opioid use treatment in EDs.
The opioid crisis affects around 2 million people in the United States alone, and as overdose rates have risen over time, so have opioid-related visits to EDs. Because of this, EDs are increasingly seen as important settings for treating opioid use disorder.
Buprenorphine is an effective treatment for opioid use that can relieve withdrawal symptoms from opioids such as heroin and fentanyl, help retain patients in opioid treatment, reduce opioid cravings, and reduce overdose deaths. However, previous research has found that many ED physicians do not feel comfortable initiating treatments like buprenorphine, citing reasons like lack of training, difficulty identifying patients for treatment, other ED priorities, and stigma.
In 2019, Yale researchers launched a trial aimed at understanding whether a clinical decision support tool embedded in a health care provider's electronic health record could boost initiation of buprenorphine treatment in EDs. One of the trial's findings was that the number of physicians who prescribed buprenorphine increased throughout the study.
"We wanted to know what factors were driving that," said Andrew Loza, a lecturer and clinical informatics fellow at Yale School of Medicine and senior author of the new study. "There's this adage in medicine: see one, do one, teach one. We wanted to investigate whether seeing a colleague prescribe buprenorphine contributes to an individual's likelihood of prescribing it themselves."
For the new study, the researchers used data from the Emergency Department Initiated Buprenorphine for Opioid Use Disorder trial, which took place from November 2019 to May 2021 and included 18 ED clusters across five health care systems. During the trial, 4,257 ED patient visits met the criteria for opioid use disorder and the patients were seen by a total of 1,026 clinicians.
The researchers found that the more often a clinician saw someone else initiate buprenorphine treatment, the more likely they were to start initiating it themselves. Specifically, if an individual saw someone initiate buprenorphine treatment once, they were 1.3 times more likely to prescribe it later on than someone who had not observed a colleague initiate the treatment. Those who saw treatment initiation five times were 2.7 times more likely to prescribe buprenorphine later, and those who saw 10 instances of treatment were 3.6 times more likely to prescribe it.
"The more you see it, the more likely you are to do it yourself," said Loza.
The study also found evidence that the individuals' clinical roles and ED culture played important roles in buprenorphine adoption. For instance, physician associates and nurse practitioners were more likely than attending physicians to adopt buprenorphine treatment. And clinicians in some health systems were more likely to initiate treatment than those in other health systems.
"Which health system a clinician was in had the biggest effect on that rate of buprenorphine adoption, which really shows that the place where you're working has a big impact," said Loza. "That was followed by clinical role, which could point to how EDs are structured or barriers to training."
One potential barrier that may have affected buprenorphine adoption was what's known as the X-waiver, which, until this year, was a training and registration process required for prescribing buprenorphine that also limited how many patients a physician could prescribe the treatment to, the researchers explained.
"We're now in a post-X-waiver era, but we still have roadblocks," said Ted Melnick, associate professor of emergency medicine at Yale School of Medicine and a co-author of the study. "Given the urgency of addressing the opioid crisis, removing those obstacles remains a priority."
Based on the study's findings, the researchers said, targeting barriers to buprenorphine treatment initiation can happen at all levels, whether from the top down, in which health care systems and ED leaders can focus on cultural and structural limitations to adoption, or from the bottom up, where individual clinicians can lead by example, influencing their colleagues as they do.
When it comes to the latter, EDs should find ways to highlight, celebrate, recognize, and empower the clinicians that adopt and spread the practice of treating opioid use disorder, said Melnick.
"We're at a critical crossroads between the health care system and individuals with opioid use disorder. EDs are where we can address the care gap for treatment," said Loza. "The potential impact of this is broad as the ED is a place where you can shift someone's trajectory dramatically."
