key: cord-1052629-knhxemu4
authors: Dong, Kathryn A.; Lavergne, Karine J.; Salvalaggio, Ginetta; Weber, Savannah M.; Xue, Cindy Jiaxin; Kestler, Andrew; Kaczorowski, Janusz; Orkin, Aaron M.; Pugh, Arlanna; Hyshka, Elaine
title: Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study
date: 2021-04-29
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12409
sha: 2c7620e7cee9c3c446fda9a915e2c5bf3041a270
doc_id: 1052629
cord_uid: knhxemu4

OBJECTIVES: The objective of this study was to examine the perspectives of Canadian emergency physicians on the care of patients with opioid use disorders in the emergency department (ED), in particular the real‐world facilitators to prescribing buprenorphine/naloxone (BUP) in the ED. METHODS: We conducted semistructured qualitative interviews using a multi‐site–focused ethnographic design. Purposive sampling via an existing national research network was used to recruit ED physicians. Interviews were conducted by phone using an interview guide and continued until theoretical data saturation was reached. Interviews were transcribed and analyzed using latent content analysis. Interviews took place between June 21, 2019, and February 11, 2020. RESULTS: A total of 32 physicians were included in the analysis. Participants had a median of 10 years of experience, and most (29/32) worked in urban settings. Clinical care of patients with opioid use disorder was found to be variable and physician dependent. Although some physicians reported routinely prescribing BUP, others felt that this was outside the clinical scope of emergency medicine. Access to clinical pathways, incentivized training, dedicated human resources, and follow‐up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient‐centered approach that enhanced patient autonomy. ED BUP prescribing became self‐reinforcing over time. CONCLUSIONS: Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow‐up care.

incentivized training, dedicated human resources, and follow-up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient-centered approach that enhanced patient autonomy. ED BUP prescribing became self-reinforcing over time.

Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow-up care. INTRODUCTION

Deaths related to opioids are of critical concern in both Canada and the United States. 1, 2 For many patients with opioid use disorder (OUD), the emergency department (ED) is often their sole or primary point of contact with the healthcare system [3] [4] [5] and represents a key access point to OUD treatment. 6 The latest available data indicate that between 2016 and 2017, the rates of opioid poisoning ED visits in Ontario and Alberta increased by 73% and 23%, respectively. 7 Of note, opioid-related harms have increased during the COVID-19

pandemic with several Canadian provinces reporting a record number of apparent opioid-related deaths. 8, 9 Buprenorphine/naloxone (BUP) is recommended as a first-line treatment for OUD, [10] [11] [12] and the initiation of BUP should be considered for all patients with untreated OUD presenting to the ED. 13 Other forms of opioid agonist treatment (OAT), such as methadone and slowrelease oral morphine, are typically subject to more regulatory requirements and have a higher risk of adverse events. BUP reduces mortality and illegal opioid use and is cost-effective. 10, 14, 15 Patients who start BUP in the ED are more likely to be retained in OUD treatment than those who receive an outpatient referral alone or in combination with a brief intervention. 12 A systematic review of ED-initiated interventions for patients with OUD found that OAT initiation, including BUP, was the most promising ED intervention; however, further research and efforts to reduce implementation barriers were recommended. 16 

Currently, there is no consensus among ED clinicians on the acceptability and feasibility of BUP initiation. Physicians view the opioid overdose epidemic as a serious concern and feel they have a duty to treat people with substance use disorders. 11, 17 Qualitative studies of ED clinicians working in US academic hospitals, however, report that some physicians feel BUP initiation is outside the scope of emergency medicine. 18, 19 This perceived incompatibility may stem in part from a lack of exposure to addiction medicine and OAT during clinicians' training years. 20 In a recent survey of Canadian physicians, although 79.9% treated patients with OUD more than once per week, only 7% of respondents always/often offered BUP in the ED. 21 In contrast to the United States, once Canadian physicians have completed the required training (if any) as outlined by their provincial or territorial regulatory body, there is no maximum number of patients that can be prescribed BUP per physician. In addition, most provinces only require completion of an online course, and several provinces have instituted phone consultation lines to assist with the management of complex patients. 22 In Canada, BUP treatment also is publicly funded through drug plans for both low-income populations and some Indigenous peoples.

Barriers to BUP initiation are well documented, particularly those perceived by US clinicians who have little to no experience with BUP; 18, 19 however, there is relatively little research that has examined the perceived facilitators of BUP initiation among emergency physicians with a range of experiences administering the treatment in the ED. Clinicians' attitudes regarding BUP initiation have been reported to shift favorably with experience as a prescriber. 11, 23, 24 As such, active prescribers may contribute a unique and important perspective.

The goal of this study was to examine the perspectives of Canadian emergency physicians on ED-initiated BUP in a sample of physicians with a range of experience in BUP prescribing and available resources.

Specifically, this study aimed to understand emergency physician experiences caring for people with OUD and to describe facilitators to prescribing BUP in the ED setting.

We conducted semistructured interviews using a multi-site-focused ethnographic design to capture the perspectives of Canadian emergency physicians on initiating BUP in the ED. Focused ethnography is a targeted, time-limited, and problem-focused form of ethnography used to understand specific social phenomena occurring within a predefined context that has distinct patterns of norms and behaviors. 25 This qualitative method is useful to identify shared practices and beliefs within a specific subgroup of individuals and is well suited to explore clinician perspectives in healthcare research. 26 

We used purposive sampling techniques to recruit emergency physicians. First, we leveraged the CRISM ED Buprenorphine Working

Group national network of ED-site research leads established for the related national quantitative survey of emergency physicians to recruit participants. Site leads selected by the working group were asked to email a description of the study and recruitment materials to emergency physicians at their respective sites, inviting them to participate in a 1-hour phone interview (Appendix 1). Interested emergency physicians contacted a research coordinator (A.P. or K.J.L.)-who had no prior or ongoing affiliation or connection to potential participantsto schedule an interview. In addition, we used snowball sampling to supplement recruitment by asking participants to share the study recruitment materials with other ED physician colleagues. Purposive sampling is common practice in qualitative inquiry, and focused ethnography as the goal is to recruit a full spectrum of key informants who can provide detailed information on a topic rather than to obtain a representative sample. 27 We set out to recruit ≈30 participants or the number required to achieve theoretical data saturation, the point at which no new information or themes tend to emerge in the data. 28 Physicians were eligible to participate if they (1) had completed their residency training, (2) had at least 1 year of experience working in an ED, and (3) were actively working in an ED in Canada for an average of at least 4 shifts per month.

We developed a semistructured interview guide (Appendix 2) to elicit emergency physician perspectives on caring for patients with OUD, and shadowed more experienced interviewers before starting independent data collection.

One-on-one interviews were conducted via the phone and audio recorded. Participants were given a study information sheet to review before participation and provided verbal informed consent via the phone (audio recorded) before commencing the interview.

Researchers used the interview guide to ask lead-off questions, then probed for clarifications and asked follow-up questions during each interview as needed. All participants were offered a $50 honorarium in consideration for their time. After each interview, the interviewers recorded field notes summarizing their overall impressions of the interview as well as key perspectives and preliminary interpretations to be further explored in subsequent interviews. Interviews were continued until theoretical data saturation was achieved. Although we obtained informed consent to recontact participants if needed, initial data collection was of satisfactory quality in all cases, and we did not need to repeat any interviews nor return transcripts to participants for comment or correction.

Before analysis, interview audio recordings were transcribed verbatim by a professional third-party transcription service, translated into English (for those completed in French), and then transcripts were checked for accuracy by 1 of the interviewers. We removed potentially identifiable participant information from the transcripts and replaced it with generic descriptions of redacted content.

We organized and analyzed the de-identified transcripts using inductive latent content analysis using NVivo 12. 29 Analysis began with data immersion. 30 

A total of 33 emergency physicians participated in the study; however, after providing consent it became apparent that 1 participant had not completed residency (ie, did not meet the inclusion criteria) and

was excluded from the analysis. All interviews were completed in full.

Characteristics of the 32 participants retained for analysis are shown in Table 2 . Interviews were conducted between June 21, 2019, and February 11, 2020. A total of 2 interviews were conducted in French (K.J.L.) and 30 were conducted in English (A.P. [1] , C.J.X. [12] , K.J.L. [14] , and S.M.W. [3] ). Interviews ranged from 36 to 75 minutes in duration (median 56 minutes).

Three key themes related to BUP initiation in the ED emerged from the analysis. 18, 19 Once treatment protocols, physician training, follow-up pathways, and other supports have been implemented, emergency physicians report that joint patient and ED system engagement becomes the limiting factor in treatment uptake. This is complicated by the stigma that remains pervasive, particularly around illegal drug use. Emergency physicians with experience in BUP prescribing reported that using patient engagement techniques, managing withdrawal symptoms in the ED, and enhancing patient autonomy were critical for successful BUP initiation in the ED. One strategy to enhance uptake and provide autonomy may be to implement take-home BUP programs in the ED.

Prescribing BUP for home initiation has the potential to (1) minimize patient discomfort in ED because patients are not made to wait in chaotic EDs and are not in withdrawal during the ED encounter, (2) support patient autonomy because patients are given the freedom to initiate the treatment on their own terms, and (3) build better rapport because prescribing for home initiation requires that the emergency physician trust the patient to initiate treatment as discussed. However, the caveat is that home initiation requires extensive treatment counseling to avoid problems of precipitated withdrawal, a problem that could be overcome by delegating treatment counseling onto experienced support staff or specialized addiction human resources and by providing patients with easy-to-read and patient codesigned preprinted information and instructions. Home BUP initiation was also identified by Im et al as a potential way to improve patient and clinician uptake. 18 

This study was conducted in Canada, which has a universal healthcare system. has not shared any identifying information with the study team.

Thank you for your consideration of our research project.

All the best, You are being invited to participate in this study because you are a physician working in an emergency department (ED) in Canada. We are doing this study to gather ED physicians' perspectives and attitudes towards starting buprenorphine treatment for patients with an opioid use disorder who present to the ED. We are aiming to recruit a total of 30 ED physicians across Canada.

This study involves taking part in a telephone interview lasting approximately 1 hour. The interview will be audio recorded, but can be requested to be shut off at any time. During this interview we will discuss the following topics:

• Caring for patients with opioid use disorders in the ED

• Providing other interventions for patients with opioid use disorders in the ED We will also ask questions about personal and site demographics.

You do not have to answer any questions that make you feel uncomfortable.

We will collect your contact information (ie, telephone number and/or email address) to contact you in the event that we require clarification on a perspective you shared during the interview. Providing contact information is optional.

The main study findings will be published in academic journal articles and presented at academic conferences.

COULD BE BAD FOR YOU?

There are no known risks to participating in this study.

The results of this study may not directly benefit you. However, in the future the results of this study may be used to inform policy and practice relating to the treatment of patients with opioid use disorders in EDs and may lead to changes in practice that positively impact the health of patients.

No personally identifiable information, such as your name or email, will be connected to your interview responses and your identity will be kept confidential. The interview audio files will be processed by a thirdparty transcription service who will be required to sign confidentiality agreements prior to receiving the data. The audio files and completed transcripts will be transferred via a secure data sharing platform. The data from this survey will be stored electronically on a secure network drive hosted at the University of Alberta in Edmonton, AB. Paper versions of the informed consent forms (when signed and printed) will be stored in locked filing cabinets at the Royal Alexandra Hospital (Edmonton, AB). Direct quotations from your interview may be used in the final publication, however all direct and indirect identifying information will be removed (anonymized quotes any time without penalty. I will audio-record this interview, which will then be transcribed verbatim. Any information that may identify you will be removed from the transcript prior to analysis. We may use direct quotations from you in the reported findings, but these quotations will never be linked to your name; rather, we will use a generic description of your professional role to provide context for your comments.

[TURN ON AUDIO RECORDER]

We would like to collect a few demographic identifiers before we start the interview. Can you tell us your: 

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References to the increased potential for stigmatization and patient experience of stigma as a result of routine OUD screening as a perceived barrier to care. Stigma toward patients with OUD References to stigma or to lack of trust in patients as barrier to initiating BUP treatment via ED. Support patient autonomy References to using a patient-centered approach to care (in the context of BUP treatment) or to providing information and means (e.g., home initiation options)

Supportive ED infrastructure References to having adequate or abundant addiction resources to support BUP initiation in ED as (perceived) facilitator of uptake

Take-home BUP References to take-home BUP, either a full home initiation or a micro-induction regimen, as a (perceived) facilitator of uptake and as a means to reduce ED treatment burden

Divert to outpatient resources References to diverting patients with OUD wanting to start BUP treatment to OAT clinics or community prescribers in settings staffed with addiction experts that provide wraparound supports in a calmer, more appropriate environment as a means to reduce ED treatment burden. Establish good rapport References to building good patient-provider rapport (trust, honesty

Experience References to acquiring or having acquired experience delivering treatment in ED or via preceptorships or clinic appointments as a (perceived) facilitator of uptake

References to having experienced support staff (nurses, social workers) with basic knowledge of treatment, induction protocols, and/or community resources as a (perceived) facilitator of uptake

Formal OAT training References to OAT training acquired via continuing medication education or emergency medicine training programs, ideally tailored for physicians, as a (perceived) facilitator of uptake. Harm reduction philosophy References to a harm reduction philosophy or approach to care, or to the treatment's potential for reducing opioid use-related harm as a motive or facilitator of uptake. Integrated addiction clinics References to addiction clinics adjacent to, or integrated within the ED or hospital as a (perceived) facilitator of uptake

Lack adequate protocols References to a lack of standardized protocols or pre-printed order sets for BUP initiations, or to inadequate protocols as barrier to uptake. Lack experience References to lack of experience administering treatment (e.g., concerns of precipitated withdrawal) as barrier to uptake. Lack motivation to train and treat References to lack of physician motivation to acquire OAT training or to offer and initiate BUP

Lack OAT training (generalists)

References to a lack of OAT training or to the omission of OAT training in emergency medicine (generalist) training programs as a barrier to uptake

Limited ED resources References to limited ED resources as a barrier to uptake

References to lack of or to limited access to specialized, dedicated, and/or experienced human resources to initiate treatment or assist with BUP initiation processes as barrier to uptake

Low concerns of misuse and diversion References to low concerns regarding BUP medication being misused or diverted to the illegal market

Mentors References to seeking advice from physicians with addiction medicine training either in person or by phone as a (perceived) facilitator of uptake

Minimize patient discomfort References to minimizing patient discomfort in ED by initiating BUP treatment in ED, by managing withdrawal symptoms in preparation for BUP initiation or in response to BUP-induced precipitated withdrawal, or by discharging patients with BUP medication for self-initiation as a (perceived) facilitator of uptake

References to observations of increased BUP treatment awareness and uptake by care providers and patients. Unreliable follow-up care References to unreliable access to OAT clinics/prescribers or to lack of pre-established care pathways for follow-up care as barrier to uptake

buprenorphine/naloxone; ED, emergency department; OAT, opioid agonist treatment; OUD, opioid use disorder

Motivation to train and treat References to physician motivation to acquire OAT training or to offer and initiate treatment in ED.

References to lack of routine screening, physician over-reliance on patients with OUD stereotypes, or physician failure to discuss opioid use with patients as a barrier to uptake.OAT education (via ED) References to OAT education and training received via the ED (in-service, meetings, journal clubs), often about induction protocols or follow-up care pathways, as a (perceived) facilitator of uptake. (Also relates to "experienced staff" code under Human Resources subtheme below.)

References to patients' alert cognitive state, ability to understand and follow instructions, and social determinants of good health as a (perceived) facilitator of patient engagement and compliance with treatment.

References to patients' social determinants of poor health (lack of housing, transportation) or cognitive impairment as a barrier to uptake.

References to patients' concerns about precipitated withdrawal, bad previous experiences with BUP, or aversion to OAT and BUP as a barrier to uptake.Patient self-disclosure References to patient self-disclosure of opioid use or OUD as a (perceived) facilitator of uptake.

References to patient lack of motivation of change their opioid use (precontemplative) or unwillingness to undergo BUP treatment because of aversion to withdrawal symptoms as a barrier to uptake.

References to patients' motivation to change (contemplative) or requests for treatment as a facilitator of uptake.Perceived ED incompatibility References to physician beliefs that emergency medicine and ED (i.e., acute care) are incompatible with long-term treatments for chronic conditions, like BUP.Perceived ED responsibility References to physician beliefs that ED has an obligation or responsibility to offer and initiate BUP as a (perceived) facilitator of uptake.Physician clinical gestalt (to identify high risk patients)References to using clinical gestalt or forming patient impressions based on available data-including information gathered from prescription monitoring programs and medical records-to identify potential candidates as a (perceived) facilitator of uptake.Physician discussion of opioid useReferences to directly asking patients about their opioid use to identify high risk patients as a (perceived) facilitator of uptake.Physician resistance to systematic screeningReferences to a lack of evidence demonstrating the effectiveness of systematic screening, to the unavailability of OAT or other interventions to offer patients who screen positive, or to increased ED burden of screening as a barrier to uptake.Practice variance References to differences in physician willingness and ability to offer and initiate BUP treatment in the ED that result in practice variance.Proactive approach References to physician beliefs that every ED encounter is an opportunity to intervene or that treatment should be initiated at first point of contact with health care system.

References to taking time to provide adequate treatment counselling so that patients know what to expect and how to take the medication properly to avoid precipitated withdrawal as a facilitator of uptake.Reliable access to medication References to reliable availability of BUP medication in ED as facilitator of uptake.Routine OUD screening References to routine, systematic, or standardized OUD screening processes, either universal or targeted based on patient risk factors, as a (perceived) facilitator to uptake.

References to BUP induction protocols and/or pre-printed order sets, particularly their potential for mitigating precipitated withdrawal concerns, as a (perceived) facilitator of uptake.Stigma conundrum (patient identification)

Team (consensus) approach References to the need for all ED care providers (physicians, nurses, social workers) to work together as a team and support each other, have an ED culture favorable to BUP treatment as (perceived) facilitator of uptake.Timely access to OAT prescribers (for follow-up)References to timely, reliable access to OAT prescribers or clinic for follow-up care and treatment maintenance as a (perceived) facilitator of uptake.Transitional care References to resources and services to bridge the gap between the ED and follow-up care, such as prescribing BUP, providing transportation, or holding patients in ED overnight, as a (perceived) facilitator of uptake.Treat straightforward cases, offload othersReferences to low patient complexity as a (perceived) facilitator and/or to high patient complexity or unsuitability for ED initiation as a barrier to uptake.Treatment is appropriate for ED References to ED as an appropriate place to initiate BUP.

References to high level of resources needed to initiate BUP in ED as barrier to uptake.

References to positive perceptions of BUP treatment safety and effectiveness.Treatment uptake is increasing