Guest Editorial: Beyond Buprenorphine in the ED: Leveraging Lessons From 10 Years of Implementation

 

Nikki Bozinoff, MD, MSc

Elizabeth Schoenfeld, MD, MS

Csilla Kalocsai, MPhil, PhD

The opioid toxicity crisis remains an urgent public health priority across the US and Canada. Since the seminal randomized controlled trial published in 2015 found that buprenorphine initiation in the emergency department (ED) was superior compared with referral to treatment alone, buprenorphine initiation in the ED has been hailed as an important mechanism for addressing the overdose crisis. However, now, nearly 10 years after the initial publication, the use of medications for opioid use disorder following an ED visit for overdose remains low with only 3-15% of individuals filling a prescription across diverse jurisdictions. Last month, we published a scoping review in Lancet Regional Health – Americas, in which we wedded a popular implementation science framework, the Consolidated Framework for Implementation Research, with critical theory to try to untangle the complex web of factors that facilitate and challenge buprenorphine induction in the ED, including the power structures that may undergird the implementation gap. We reflect on the tremendous scholarly and human resource effort to implement buprenorphine in the ED and try to unpack its implications for addiction medicine.

We found that a major facilitator of buprenorphine initiation in the ED was the structural normalization of delivering care for opioid use disorder (OUD) in the ED. By structural we refer to policies, procedures, shared values, norms, and institutional practices. These included order sets, referral pathways, observation units, multidisciplinary addiction consult teams, and endorsement by professional medical bodies. Literally, this often meant creating space for addiction medicine – in the electronic medical record, in the ED, at decision-making tables, and among other consultation services – that normalized the presence and treatment of people with OUD. In carving out these new spaces, the structural normalization of OUD care facilitated attitudinal changes among ED providers, who shifted from claiming “this is beyond the scope of my practice” to recognizing that treatment of OUD is part of high quality emergency medical care. Where this structural normalization has taken place, we now have a scaffold on which high quality treatment of other substance use disorders can be built. 

Another major focus in the literature was the transition from the ED to outpatient care. Facilitators here included low-barrier, harm reduction-informed, co-located outpatient clinics with staff working across sites of service to improve trust and continuity. Longer discharge prescriptions to allow sufficient time to attend follow-up, and care coordination (care/peer navigators, facilitation of transportation, and addressing insurance-related barriers) were also facilitators that sought to address some aspects of service users’ complex lives.

A third notable finding in the literature were the many adaptations to the pathway as originally described. These included protocols for post-naloxone initiation, protocols that addressed initiation in the era of fentanyl via low-dose or high-dose initiation, innovations to retain persons in care (such as follow-up calls and case management), and initiation of buprenorphine by emergency medical services prior to ED arrival or in the field. Together, these innovations demonstrate that our field has the capacity to adapt to the shifting landscape of opioid supply and imagine new possibilities that can improve the lives of people with substance use disorders.  

The reviewed studies, however, had a number of blind spots. The literature largely missed the opportunity to incorporate the experiences and perspectives of learners, health administrators, and people who use opioids. Important socio-demographic data were rarely reported. Much of the existing research thus failed to consider how intersecting structures - such as racism, colonialism, sexism, heteronormativity, language discordance, and capitalism - perpetuate inequitable access to treatment for OUD in the ED. Most of the articles, for example, refer to stigma as a barrier, but usually define stigma as a negative attitude rooted in the individual without diving deeper into how it might be structurally embedded. This research highlights opportunities to educate clinicians to better serve marginalized communities and calls for services that address clients’ medical and mental health comorbidities, complex social positionalities, and multiple disadvantages.

As our field considers ways to move forward in tackling the opioid crisis, we must harness the lessons learned over the past 10 years of buprenorphine initiation in the ED. We need structural normalization of substance use care in the ED and acute care more broadly. We call for attention to improving transitions from ED to outpatient care in order to improve retention. Lastly, we recognize the importance of centering questions of equity in our education, research, clinical practice, and systems advocacy. How we implement an innovation matters and is consequential for patient outcomes. Therefore, we should take more seriously the research that seeks to synthetize and that prompts us to raise critical questions: Whose perspectives do we rely on and whose are we missing? What assumptions do we make and what do we obscure by our usual ways of thinking and working? 

We should, for example, reflect on the immense implementation effort that has been based on a single medication. Methadone is as or more effective than buprenorphine for many people but has not enjoyed the same wide-spread acceptance from the field of emergency medicine, limiting its availability in acute care. Many of the barriers to ED initiation of methadone are similar to those we’ve discussed – structural inadequacies, stigma, poor coordination of care, regulatory barriers, and economic imperatives. Nonetheless, if we center patients’ needs and preferences, we may be tasked with imagining ‘care pathways for persons who use opioids’ in all their complexity, rather than ‘buprenorphine initiation pathways.’ We must offer the full spectrum of treatments for OUD and more rigorously embrace harm reduction as an ethic of care so we can create a more robust, multipronged, accessible, equitable, and inclusive response to the opioid crisis in our EDs and beyond.