119 Opioid Use Disorder Management in Canadian Emergency Departments: A Cross-Sectional Survey

Abstract

Emergency department (ED) visits for opioid use disorders (OUD) have seen a four- to ten- fold increase in the last five years across Canada. In comparison, there has been a 30% increase of OUD-related ED visits in the United States from 2016 to 2017, with limited access to treatment. There is a growing body of evidence for improving ED-based symptomatic treatment of acute opioid withdrawal, medication-assisted treatment of OUD on discharge from the ED, and the transition to outpatient services. This cross-sectional study aims to understand current management of OUD across Canadian EDs, establish a baseline understanding of OUD amongst emergency physicians, complete a needs-assessment of EDs to increase utilization of best practice guidelines, and optimize the OUD response in EDs. We completed a cross-sectional study of emergency physicians across Canada using a self-administered 16-question survey circulated through SurveyMonkey via the Canadian Association for Emergency Physicians (CAEP) survey deployment service. We used a modified Dillman methodology to develop the survey tool consisting of multiple choice, likert-scale, and open-ended questions. Descriptive statistics were used to calculate rates and averages. Surveys were fully completed by 179 physicians, or 9.7% of eligible CAEP members. Approximately half of respondents (45%) worked in community settings and half (55%) in academic settings. Most were attending physicians (83%) working in high volume EDs (81%). The majority saw patients presenting with OUD at least 1-5 times a week (43%) or more than 6 times per week (32%). Over half (54.6%) of the participants felt dissatisfied with the care their patients receive for OUDs in the ED. The most commonly reported interventions for patients with OUD included: provision of a take-home naloxone (54.1%), referral to a methadone/buprenorphine clinic (60.7%), referral to an addiction clinic (73.2%), and/or instructions to see their family physician (74.3%). Most physicians never or rarely provided buprenorphine in the ED (74%) or via outpatient script (78%). Most (89%) never or rarely provided a prescription for other medications to prevent withdrawal symptoms. Physicians identified pre-printed order sets (91%), phone (92%) or on-site (88%) access to addiction specialists, on-site case managers (93%), and rapid access to addictions clinics (73%) as useful supports. Respondents identified written protocols as the most useful educational tool, followed by in-person presentations (75%) and brief online learning modules (75%). Clinical guidelines now strongly recommend buprenorphine as first line treatment for OUD, and ED-initiated and ED-prescribed buprenorphine have been found to be both feasible and effective. However, buprenorphine for OUD is currently underutilized in Canadian EDs, and only half of physicians surveyed routinely offer take-home naloxone. The reasons for this are likely multifactorial and systemic, and naloxone and buprenorphine may not always be available in EDs. Uptake of evidence-based recommendations may work to improve ED provider satisfaction in caring for patients with OUD. We will seek options to rapidly disseminate the simple interventions identified in this study, including pre-printed order sets and protocols.