CLINICIAN'S CAPSULE
What is known about the topic?
Buprenorphine is the first-line treatment for opioid use disorder, and many patients with this disorder present to the emergency department (ED).
What did this study ask?
How do emergency physicians manage opioid use disorder; are they satisfied with their management; and what resources are needed to improve management?
What did this study find?
Buprenorphine is infrequently prescribed in the ED, and physicians are largely dissatisfied with current management, finding various on-site supports useful.
Why does this study matter to clinicians?
Understanding opioid use disorder management, provider satisfaction, and needed resources can help design appropriate supports for ED physicians to effectively manage this disorder.
INTRODUCTION
Opioid use disorder is a problematic pattern of opioid use leading to clinically significant impairment or distress.1 Over the last decade, North America has seen a rapid increase in opioid-related mortality with 3,987 opioid-related deaths in Canada in 2017, a 34% increase from 2016.2 On average, there are 13 emergency department (ED) visits daily due to opioid poisoning in Ontario.3 EDs and healthcare institutions are still integrating new guidelines as this public health crisis continues to evolve.
The newest Canadian guidelines for opioid use disorder management, published in the Canadian Medical Association Journal in 2018, recommend opioid agonist treatment with buprenorphine-naloxone (hereinafter referred to as buprenorphine), trade name Suboxone, as first-line treatment for opioid use disorder.Reference Bruneau, Ahamad and Goyer4 Recent evidence suggests that ED visits are an opportunity to initiate treatment for opioid use disorder. ED-initiated buprenorphine increases engagement in addiction treatment and reduces self-reported illicit opioid use at 2 months.Reference D'Onofrio, Chawarski and O'Connor5 An Ontario study showed that prescribing buprenorphine in the ED resulted in fewer ED visits at 3- and 6-month follow-ups.Reference Hu, Snider-Adler, Nijmeh and Pyle6
Guidelines recommend buprenorphine as first-line treatment in managing opioid use disorder, and ED visits for opioid intoxication and withdrawal present an opportunity to initiate treatment. Our objectives are to understand current practices when treating opioid use disorder, emergency physician satisfaction with current practices, and the resources needed to improve the care of people with opioid use disorder in the ED.
MATERIALS AND METHODS
Study design
We developed a cross-sectional survey and administered it electronically through SurveyMonkey from September to November 2018. We distributed the survey to emergency physicians across Canada using a survey deployment service from the Canadian Association of Emergency Physicians.
We pilot tested the survey with two emergency physicians based in academic hospitals who practise addiction medicine in the Greater Toronto region, and incorporated revisions based on feedback. The 16-question survey consisted of multiple choice and Likert-scale questions (see Appendix A for survey tool).
Data analysis
We summarized the survey results as frequencies and percentages using descriptive statistics. SAS (version 9.4) was used for statistical analysis. Likert scales were dichotomized in order to be able to approximate relative risk ratios via log binomial analysis. A value of p ≤ 0.01 was considered statistically significant to account for multiple comparisons. We did not analyse the qualitative data due to low participation and brevity of answers.
Ethics and confidentiality
This project has received ethics approval from the University of Toronto (Project number 00036313). No financial or non-monetary incentives were offered for participation.
Participants
In 2018, the Canadian Association of Emergency Physicians had a total of 1,975 physicians and resident members. The 1,606 resident and staff physician members who opted into the research mailing list were eligible to participate. Junior residents were defined as PGY1/2 respondents, and senior residents were defined as PGY3/4/5/6 respondents.
RESULTS
Demographics
Of the 1,606 eligible members, 179 completed the survey for a response rate of 11.1%. Participant demographics are presented in Table 1 in Appendix B. Most respondents saw patients with opioid use disorder regularly, and nearly a fifth of respondents did so more than 10 times per week (n = 34, 19%). Most physicians worked in high volume EDs (n = 145, 81%).
Current management of opioid use disorder
Physicians varied in their approach to treating opioid use disorder. Physicians reported doing the following interventions always or often: referring to an addiction clinic where patients could be seen within the next few days (42.4%, n = 76), providing naloxone kits (39%, n = 70), and referring patients to withdrawal management services (38.5%, n = 69). A minority of respondents reported often or always providing buprenorphine in the ED (7.3%, n = 13) or an outpatient script for buprenorphine (5%, n = 9) (see Figure 1).
Figure 1. Current opioid use disorder management practices by Canadian ED physicians (n = 179).
A log binomial analysis (Table 2 in Appendix F) showed that ED providers who treat patients with opioid use disorder more than 10 times per week were 5 times more likely to prescribe buprenorphine in the ED (RR = 5.6, CI = 1.77–17.67, p < 0.01). Physicians who treated opioid use disorder more often in the ED were more likely to refer patients to an addiction clinic. Compared to physicians who treat opioid use disorder less than once a week, physicians who treat opioid use disorder 1–5 times a week or more than 10 times a week were approximately 6 times more likely to refer to an addiction clinic (RR = 5.8, CI = 1.92–17.48, p < 0.01; RR = 6.7, CI = 2.17–20.87, p < 0.01). No other significant correlations were observed between frequency of treating opioid use disorder and interventions.
Satisfaction with opioid use disorder management
More than half (55.3%, n = 99) of respondents were dissatisfied with the current care of patients with opioid use disorder in their ED, as demonstrated in Figure 2 in Appendix C. There were no statistically significant differences in satisfaction across type of hospital (p = 0.22), region of practice (p = 0.36), or ED volume (p = 0.26) (Table 3). Physicians who were somewhat or very satisfied with management of opioid use disorder were four times more likely to prescribe buprenorphine in the ED compared to those who were dissatisfied (RR = 4.41, CI = 2.33–8.33, p < 0.01), and were four times more likely to provide outpatient scripts for buprenorphine (RR = 4.51, CI = 2.21–9.22, p < 0.01) (Table 4 in Appendix H).
Improving care for patients with opioid use disorder in the ED
Physicians identified resources that would best support them in the care of patients with opioid use disorder (Figure 3 in Appendix D). Referral to an addiction clinic where patients could be seen in the next few days was deemed the most helpful (90.5%, n = 162). Most respondents also identified naloxone kits in the ED (80.4%, n = 144), on-site case management (80.4%, n = 144), and pre-printed order sets for buprenorphine (77.7%, n = 139) as helpful. In-person presentations on opioid-related conditions (36.3%, n = 65) and brief online modules (34.6%, n = 62) were only rated as useful by a minority of respondents (Figure 4 in Appendix E).
DISCUSSION
The new Canadian guidelines recommend buprenorphine as first-line treatment for opioid use disorder; our findings suggest that emergency physicians prescribe it infrequently both in the ED and as outpatient prescriptions. Literature in various clinical settings suggests that a combination of physician education, on-site expert consultation, availability of care coordinators, and access to follow-up care facilitates evidence-based treatment of opioid use disorder.Reference Netherland, Botsko and Egan7,Reference Lowenstein, Kilaru and Perrone8 Our results suggest a role for mentorship, which has been shown to facilitate physician prescribing of buprenorphine.Reference Netherland, Botsko and Egan7,Reference Andrilla, Moore and Patterson9
Evidence-based harm-reduction approaches to opioid use disorder in the ED will require a comprehensive knowledge translation strategy. The solutions highlighted here include connecting physicians to mentors and educational initiatives, as well as enhancing departmental support through clinical protocols, pre-printed order sets, and expansion of low-barrier addiction clinics linked to the ED. The impact of some of these measures is being formally studied elsewhere.Reference D'Onofrio, Edelman and Hawk10 However, the need for action is urgent; EDs should not wait for further research before adopting these strategies and facilitating access to evidence-based treatment of opioid use disorder. Given that prescribing buprenorphine was positively correlated with satisfaction, improving availability of support, training, and coordination of care for patients with opioid use disorder may rapidly help increase the frequency of prescribing buprenorphine amongst emergency physicians, and improve physician satisfaction with their care.
Our study analysis was limited by a small sample size and low participation rate. We were unable to control for potential confounders given the small sample size. These results reflect the experiences of physicians working mainly in urban centres and physicians self-selected to participate, which may introduce selection bias.
CONCLUSION
This study found that physicians are largely unsatisfied with the care for patients with opioid use disorder in the ED, and practices are not aligned with the Canadian guidelines on the management of opioid use disorder. ED physicians value on-site supports, including care coordination and addiction consult services, as well as timely, easily available outpatient care for patients with opioid use disorder. EDs should implement knowledge translation strategies to improve the care of patients with opioid use disorder.
Supplemental material
The supplemental material for this article can be found at https://doi.org/10.1017/cem.2020.362.
Competing interests
None declared.
