Abstract
BackgroundEmergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine.MethodsWe purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach.ResultsResults fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes.ConclusionThis study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department.
Highlights
Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD)
Facilitators to managing opioid withdrawal included the presence of physician champions and positive experiences with opioid agonist therapy, as well as system-level factors such as the availability of order sets and timely access to follow-up for patients
Our study found that a significant facilitator to adoption of buprenorphine in the ED was the presence of physician champions who led departmental change, consistent with literature which shows that role modeling builds physician comfort with new practices [27, 28]
Summary
Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). OUD is a cause of significant and increasing harm, with 14,700 opioid-related deaths in Canada between January 2016 and September 2019 [2]. During this time period, 1 in 4 patients seen in EDs for opioid-related poisonings were admitted, resulting in 19, 490 hospitalizations [2]. A recent Canadian clinical guideline recommends the use of the opioid agonist medication buprenorphinenaloxone (trade name Suboxone), from here on referred to as buprenorphine, as first-line treatment for OUD [3]. Retention on buprenorphine treatment has been shown to reduce ED utilization [10]
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