Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine

Abstract

Importance: Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians.

Objective: To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types.

Design, setting, and participants: Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020.

Main outcomes and measures: Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively.

Results: Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care.

Conclusions and relevance: Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hawk reported receiving grants from the National Institute on Drug Abuse (NIDA)/National Institutes of Health (NIH) during the conduct of this study. Dr D’Onofrio reported receiving grants from the NIDA/NIH, during the conduct of the study. Dr Chawarski reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Cowan reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Lyons reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Richardson reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Rothman reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Whiteside reported receiving grants from the NIDA Center for the Clinical Trials Network (CTN) and the NIDA/NIH during the conduct of the study. Ms Owens reported receiving grants from the NIDA/NIH during the conduct of the study. Ms Martel reported receiving grants from the NIDA/NIH during the conduct of the study. Dr Pantalon reported receiving personal fees from Center for Progressive Recovery outside the submitted work and funding from the NIDA/NIH during the conduct of the study. Dr Fiellin reported receiving grants from the NIDA/NIH during the conduct of the study and honoraria from Springer Nature, Boston Medical Center, University of New South Wales, University of Alabama, Birmingham, US Department of Justice, Tufts University, American Society of Addiction Medicine, American Academy of Addiction Psychiatry, Boston University, and University of Kentucky. Dr Edelman reported receiving grants from the NIDA/NIH during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Organizational Readiness to Change Assessment (ORCA) Evidence Subscales by Readiness to Initiate Buprenorphine Treatment in the Emergency Department

Data are expressed as mean scores; error bars indicate 95% CI. aP < .001 bP = .001

Figure 2.. Organizational Readiness to Change Assessment (ORCA) Context Subscales by Readiness to Initiate Buprenorphine Treatment in the Emergency Department

Data are expressed as mean scores; error bars indicate 95% CI. aP = .02.