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Fig. 1 shows physician self-rated preparation for OUD care. While physicians felt prepared for some aspects of care, a minority felt pre- pared to determine the level of care for patients with OUD (39%), con- nect patients to outpatient treatment (29%) or initiate buprenorphine (27%). Levels of preparation did not differ significantly by X-waiver sta- tus, with the exception of initiating buprenorphine treatment (56% of waiver trained physicians vs 20% of non-waiver trained, p = 0.002). Preparation also did not differ by level of training.

Fig. 2 shows physician-rated barriers and facilitators to ordering buprenorphine in the ED. Many of the highest-rated concerns related to perceived patient factors, including patient social barriers, lack of patient interest in treatment, availability of referrals for substance use treatment, and patient preference for alternative treatments (e.g. non-medication based). Other highly rated barriers related to buprenorphine - comfort in counseling, ordering, or navigating regulatory barriers - differed signif- icantly between those who had completed the waiver training and those who had not, with a mean rating 4.9 vs 6.3 (p = 0.030); 3.1 vs 6.4 (p = 0.001); and 3.4 vs 6.4, (p b 0.001), respectively. The highest rated facilitators for buprenorphine ordering related to longitudinal treatment, including access to ongoing treatment services after discharge and access to a care coordinator/social worker for patients with OUD. Other highly rated facilitators related to support for ED-based treatment, including

Barriers and facilitators for emergency department initiation of buprenorphine: A physician survey

Implementation of evidence-based pharmacotherapy for individuals with Opioid use disorder (OUD) is a cornerstone of the response to the

Table 1

Participant characteristics.

Physician characterstics Age

b30 30-39

opioid crisis [1]. ED-initiated OUD treatment with buprenorphine has	40-49	15 (18%)	6	9
been shown to increase treatment engagement at 30 days [2], but this	50-59	7 (8%)	1	6
practice has not been widely adopted [3]. To better develop strategies for implementation, we sought to 1) describe ED physician prepared-	Over 60 Sex	3 (4%)	0	3	p = 0.149

Number X-waiver? No X-waiver p-Value??

24 (29%)	2	22
35 (42%)	9	26

0

ness to treat OUD and 2) rank physician-perceived barriers and facilita- Female 32 (38%)			5	27
Male 52 (62%)			13	39	p = 0.309
tors of ED administration of buprenorphine and obtaining a Drug Ethnicity
Addiction Treatment Act of 2000 waiver to prescribe buprenorphine	Hispanic/Latino	4 (5%)	0	4
(X-waiver).	Non-Hispanic/Latino	80 (95%)	18	62	p = 0.573
To do this, we conducted a cross-sectional survey of physicians in two urban, academic EDs assessing two domains. First, we measured	Race White Black/African American	62 (74%) 0 (0%)	13 0	49
self-rated levels of preparation for various aspects of OUD treatment	Asian	13 (15%)	4	9
using a 5-point Likert scale. Second, we assessed barriers and facilitators	Other	9 (11%)	1	8	p = 0.561
to buprenorphine administration in the ED and obtaining and X-waiver.	Level of Training

Barriers were based on those identified in prior literature from other settings [4-9]. Barriers and facilitators were rated individually on a con- tinuous 10-point scale, with 1 indicating “not at all a barrier” and 10 in- dicating “the most significant barrier.” We also collected demographic and other physician characteristics. The survey was administered via the REDCap version 8.9.0 secure web platform [10], and participants re- ceived a $10 incentive. Data were analyzed using descriptive statistics, and we compared responses by X-waiver status using chi-squared tests for categorical variables and the Mann-Whitney test for continu- ous variables (Stata, version 15.1; StataCorp, College Station, TX). The Institutional Review Board from The University of Pennsylvania ap- proved this study.

84 participants completed the survey (response rate 78%). Partici- pant characteristics are shown in Table 1. Participants were primarily male (62%), white (74%), and attending physicians (55%). Characteris- tics were similar for the 21% who had completed X-waiver training and those who had not. 39% of physicians reported they had ordered naloxone upon discharge from the ED in the past 3 months, and 33% had ordered buprenorphine in the past 3 months, either in the ED or at discharge.

Intern	8 (10%)	0	8
Resident	29 (35%)	4	25
Attending	47 (56%)	14	33	p = 0.077

PGY5-9 18 (21%)

PGY10-14 9 (11%)

PGY15+	20 (24%)
Percent Time in Clinical Care b20%	2 (2%)	1	2
20-50%	10 (12%_	1	9
51-75%	10 (12%_	3	7
N75% Close friend/family with SUD	61 (73%)	13	48	p = 0.690
Yes	24 (29%)	6	18	p = 0.668

Practice characteristics

X-waiver training completed

Yes 18 (21%) n/a n/a n/a Ordered Naloxone in past 3 months

Yes 39 (46%) 12 27 p = 0.052

Ordered Buprenorphine for a patient in past 3 months

Yes 28 (33%) 8 20 p = 0.259

* Includes those with an X-waiver and those who had recently completed X-waiver training but had not yet obtained a waiver.

?? p-value for comparison of X-waivered vs non X-waivered physicians done using chi²

tests (p b 0.05).

Fig. 1. Level of preparation for treatment of OUD in the emergency department Displayed are the percentage of physicians who rated that they were either “somewhat prepared” or “very prepared” to address each of the aspects of OUD care in the emergency department. The asterisk indicate those responses that significantly differed by X-waiver status. OUD: opioid use disorder; COWS: Clinical Opioid withdrawal Scale.

A.

0

1

2

3

4

5

6

7

8

9

10

Patient social barriers Lack of patient interest in treatment

Availability of referrals for OUD treatment at disharge Patient preference for other treatment

*Comfort with Counseling about Buprenorphine

*Comfort with Ordering buprenorphine

*Regulatory concerns related to prescribing buprenorphine

Time Constraints Availability of social work/care coordination

*Availability of protocols for initiating buprenorphine

Availability of nursing support Access to expert physician consultation

*Availability of Buprenorphine

*Concerns about misuse or diversion of buprenorphine

*Safety of Buprenorphine

B.

0

1 2 3

4

5

6

7

8

9

10

Access to ongoing treatment services after discharge Access to dedicated care coordinator/social worker Ordersets for OUD treatment in the EMR Availability of pharmacist consulation

Availability of peer counselors Clinical Decision Supprt in EMR

Availability of expert physician consultation Education about regulatory concerns

*Screening for OUD at triage

All providers No Waiver

Completed Waiver Training

Fig. 2. Barriers and Facilitators to Ordering Buprenorphine in the Emergency Department. Panel A shows survey results for physician-rated barriers on a scale from 1-10 (10 being the most significant barrier). Panel B shows physician-rated facilitators for ordering buprenorphine in the emergency department. The asterisks indicate those responses that significantly differed by X-waiver status (p b 0.05). OUD: opioid use disorder; EMR: electronic medical record.

A.

0 1 2 3 4 5 6 7 8 9 10

The process is inconvenient Requires uncompensated time outside work

Don’t know the process Cost of obtaining the waiver

A waiver is not necessary for my practice I am not confident in my ability to treat patients with OUD

I don’t want to be one of the few prescribers in my department

B.

0

2

4

6

8

10

Waiver training counts as one of my shifts Financial incentive for obtaining the waiver Waiver training day through my department Responsibility for teaching trainees

Waiver training at a professional society meeting

Public recognition in my department

Fig. 3. Barriers and Facilitators to obtaining an X-waiver for emergency department physicians. Panel A shows survey results for physician-rated barriers to obtaining an X-waiver among those who had not completed a waiver training on a scale from 1 to 10 (10 being the most significant barrier). Panel B shows physician-rated facilitators for obtaining an X-wavier. OUD: opioid use disorder.

electronic medical record order sets, pharmacist consultation and avail- ability of peer counselors.

Finally, we asked the 66 physicians who had not yet completed X- waiver training about barriers and facilitators to obtaining an X- waiver (Fig. 3). The highest rated barriers to obtaining an X-waiver were the inconvenience of the process and uncompensated time out- side work. Top-rated facilitators included substituting training for a shift and financial incentives.

Our results contribute to translation of evidence into practice for

ED-initiated addiction treatment in several key ways. First, while most physicians felt unprepared for referral and treatment with buprenorphine in the ED, X-waiver training was associated with higher self-rated preparation, suggesting that interventions to address knowl- edge or confidence gaps may increase buprenorphine implementation. However, the most significant physican-reported barriers to ordering buprenorphine related to perceived patient, logistical or systemic factors. These barriers did not differ by X-waiver status, suggesting that they may not be mitigated by waiver training or other educational interventions alone. Promising strategies to address these barriers and increase treatment include Multidisciplinary teams with social workers and peer specialists, development of treatment and referral protocols, and other supports that address patient or system-level barriers [11]. Finally, our findings demonstrate that the burden of X-waiver training poses challenges. Incentives may be one effective strategy for overcom- ing barriers, but they may need to be further reduced through regulatory changes to ease the burden of the X-waiver training [12]. As ED-initiated treatment expands, it will be critical to develop interventions that address not only provider knowledge but also patient and system-level challenges.

Funding sources

Dr. Lowenstein and Dr. Kilaru are funded by the Department of Vet- erans Affairs through the National Clinician Scholars Program. Addi- tional funding was provided by NIH K23HD090272001 (Dr. Delgado).

Prior presentations

None.

Disclosures

ML, AK, JP, ZFM report no conflicts of interest.

MKD received an honorarium for participating in an Expert Roundtable on opioid prescribing convened by United Health Group.

Margaret Lowenstein, MD, MPhil* National Clinician Scholars Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States of America

The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America

*Corresponding author at: 1310 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States of America.

E-mail address: [email protected].

Austin Kilaru, MD National Clinician Scholars Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America

Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

Jeanmarie Perrone, MD Zachary F. Meisel, MD, MPH, MSHP

The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

Jessica Hemmons, MS Dina Abdel-Rahman, MS

Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America

M. Kit Delgado, MD, MS The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania,

Philadelphia, PA, United States of America Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United

States of America

7 February 2019

https://doi.org/10.1016/j.ajem.2019.02.025

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    Lack of associations of substance use and mental health with self-reported pain scores among emergency department patients

    The most common complaint among Emergency Department (ED) patients is pain [1]. Pain scores have been shown to be influ- enced by factors such as race, age, and gender [2-4]. Addiction disorders are frequently encountered in the ED environment [5- 7].

    The Addiction Severity Index (ASI) is a validated measurement tool as objectively assess addiction [8,9]. This study was under- taken to measure the prevalence and severity of addiction and its relationship to self-reported pain and Mental illness among ED patients.

    This prospective survey study was conducted at Miami Valley Hospi- tal, an urban hospital emergency department. The study was approved by the Wright State University Institutional Review Board. Participants were enrolled by research assistants during June through August of 2018. Eligible participants were at least 18 years of age with a triage pain score of 1 or higher (on a 0-10 scale). Primary outcome measures included substance abuse, mental health, and self- reported pain scores. Portions of the ASI used in this study included information regarding al- cohol use, drug use, and mental health.

    Among 473 eligible participants, 360 consented to participate (76% participation rate). The mean age was 40 (range 18 to 85). Participants reported an average triage pain score of 7 (range 1 to 10). The current episode of pain had a mean duration of 2 days. In addition, 49.5% of par- ticipants suffered from chronic pain, including back pain (25%), mi- graine headache (6%), neck pain (6%), and other types of chronic pain (63%).

    The most common substance reported was alcohol. Forty-one percent (N = 146) of participants reported some alcohol use in the past 30 days, with 8% reporting drinking to intoxication (Fig. 1). cannabis use was also commonly reported. Twenty-seven percent (N = 96) of participants reported cannabis use in the past 30 days, with the majority reported use at least 3 times (78%) and a minority reporting daily use (33%) (Fig. 2). Other sub- stances reported by participants included cocaine (3%; N = 11), amphetamines (2%; N = 6), heroin (1%; N = 2), other opiates

    (18%; N = 64), and other substances (11%; N = 40).

    The prevalence of mental illness was high. Within the past 30 days, 34% (N = 122) of patients reported experiencing serious anxiety or ten- sion and 27% (N = 96) reported difficulty understanding, concentrating, or remembering, and 22% (N = 79) reported serious depression. Four percent (N = 11) reported serious thoughts of suicide. A significant number of participants had been treated for mental health as an outpa- tient (28%; N = 100) or as an inpatient (21%; N = 77).

    There was no association between self-reported pain scores and sub- stance use. Anxiety was associated with higher self-reported pain scores (p = 0.03) (Table 1). There was no association between chronic pain and triage pain scores. Participants with chronic pain were more likely to experience higher rates of depression, anxiety, and suicidal thoughts (p b 0.001; Table 2).