Abstract
Buprenorphine (BUP) can safely and effectively reduce craving, overdose, and mortality rates in people with opioid use disorder (OUD). However, adoption of ED-initiation of BUP has been slow partly due to physician perception this practice is too complex and disruptive. We report progress of the ongoing EMBED (EMergency department-initiated BuprenorphinE for opioid use Disorder) project. This project is a five-year collaboration across five healthcare systems with the goal to develop, integrate, study, and disseminate user-centered Clinical Decision Support (CDS) to promote the adoption of Emergency Department (ED)-initiation of buprenorphine/naloxone (BUP) into routine emergency care. Soon to enter its third year, the project has already completed multiple milestones to achieve its goals including (1) user-centered design of the CDS prototype, (2) integration of the CDS into an automated electronic health record (EHR) workflow, (3) data coordination including derivation and validation of an EHR-based computable phenotype, (4) meeting all ethical and regulatory requirements to achieve a waiver of informed consent, (5) pilot testing of the intervention at a single site, and (6) launching a parallel group-randomized 18-month pragmatic trial in 20 EDs across 5 healthcare systems. Pilot testing of the intervention in a single ED was associated with increased rates of ED-initiated BUP and naloxone prescribing and a doubling of the number of unique physicians adopting the practice. The ongoing multi-center pragmatic trial will assess the intervention’s effectiveness, scalability, and generalizability with a goal to shift the emergency care paradigm for OUD towards early identification and treatment.Trial Registration:Clinicaltrials.gov # NCT03658642.
Highlights
The opioid epidemic is a public health crisis that has devastated countless families and communities in the United States [1,2]
We present our progress toward accomplishing these goals, including: (1) designing the user-centered Clinical Decision Support (CDS), (2) integrating the CDS into an automated electronic health record (EHR) workflow, (3) derivating and validating an EHR-based computable phenotype to identify potentially eligible patients, (4) meeting all ethical and regulatory requirements to achieve a waiver of informed consent, (5) pilot testing the intervention at a single site, and (6) launching a parallel group-randomized trial in 20 Emergency Department (ED) across 5 healthcare systems to evaluate the effectiveness and scalability of the intervention
This led to the development of a flexible design offering direct care pathways for more experienced users as well as additional, optional decision support for less-experienced users needing assistance with assessing for opioid use disorder (OUD), evaluating withdrawal severity, and motivating patients’ readiness to start treatment
Summary
The opioid epidemic is a public health crisis that has devastated countless families and communities in the United States [1,2]. In 2011, there were 605,000 opioid-related emergency department (ED) visits [5]. There was a 30% increase in ED visits for opioid overdose between 2016 and 2017 [6]. Of 11,557 ED patients in Massachusetts who were treated for a non-fatal opioid overdose, 5.5% died within 1 year, 1.1% within 1 month, and 0.25% within 2 days [7]. Patients discharged from the ED following a non-fatal opioid overdose face a high short-term risk of death. Emergency clinicians have a unique opportunity to initiate addiction treatment that could prevent a subsequent fatal overdose. Emergency clinicians have historically provided treatment for the immediate complication of addiction that prompted the ED visit, relying on community-based opioid treatment programs (OTPs) to initiate MOUD) [8]
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