Article

One million screened: Scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland

a b s t r a c t

Purpose: Identification of problematic alcohol use and substance use in the population has been a clinical chal- lenge, especially during the heightened years of the opioid epidemic. Bringing Screening, brief intervention, and referral to treatment (SBIRT) to scale in medical settings, such as hospital emergency departments (EDs) could facilitate broad identification of Substance use disorders, timely delivery of brief interventions, and success- ful linkages to treatment.

Procedures: This large-scale data analysis pulled electronic health record data from 23 hospitals in the state of Maryland for over 1 million patient visits between July 2014 and November 2018.

Findings: Of the 1,097,142 ED patients screened, 17.2% screened positive for problematic alcohol or any drug use in the previous 12 months. During this same period, 79,899 brief interventions were delivered, 15,961 referrals to outpatient treatment were made and 38.3% of those were successfully linked to treatment. Of the 950 patients exhibiting Withdrawal symptoms, over two-thirds patients (70.1%; n = 666) were administered buprenorphine, 94.6% (n = 630) accepted a referral to buprenorphine treatment in the community, and 64.6% (n = 430) attended their first outpatient buprenorphine treatment visit. A total of 2382 patients presented to the ED with a suspected opioid overdose, over half were referred to the intervention program (53.8%) and 63.2% were successfully engaged by the PRCs in the ED. Conclusions: This analysis supports the scalability of SBIRT in hospital EDs and presents an implementation model that can be replicated in EDs nationwide.

(C) 2020

Introduction

In 2016, over 20 million Americans were estimated to need treat- ment for alcohol or Drug use disorder, yet only 1 in 10 received it [1]. The ongoing opioid epidemic has exacted nearly 400,000 deaths from overdose between 1999 and 2017 [2]. Hospital Emergency Departments (EDs) are recognized as an important venue for intervention, given their

Abbreviations: SBIRT, Screening, brief intervention, referral to treatment; OUD, Opioid use disorder; CHSURP, Comprehensive hospital substance use response program; PRC, Peer recovery coach; SOR, State opioid response; EHR, Electronic health record; ED, Emergency department; AUDIT C, Alcohol use disorders identification test – consumption; BI, Brief intervention; COWS, Clinical opiate withdrawal scale; OTP, Opioid treatment pro- gram; IOP, Intensive outpatient; PCP, Primary care provider; OSOP, Opioid overdose survivor’s outreach program.

* Corresponding author.

E-mail address: [email protected] (L.B. Monico).

patients’ high rates of substance involvement relative to the general population [3,4]. Compared to alcohol, evidence of the effectiveness of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for drug misuse in EDs has been relatively limited [5], until efforts to add initiation of pharmacotherapy for nicotine and opioid use disorders to SBIRT [6]. In recent years, some hospital EDs in various communities have begun to offer buprenorphine initiation and treatment referrals [7]. However, this remains the exception, and bringing these services to scale has been a challenge.

In the current article, we report on a state-wide effort in Maryland to expand SBIRT in hospital EDs, with a focus on treatment initiation and referral for patients with Opioid use disorder . The Comprehen- sive Hospital Substance Use Response Program (CHSURP) integrates three components of substance use services in EDs throughout the state: (1) SBIRT using universal substance use screening and Peer Re- covery Coach model for interventions and referrals, (2) Community-

https://doi.org/10.1016/j.ajem.2020.03.005

0735-6757/(C) 2020

buprenorphine administration initia”>L.B. Monico et al. / American Journal of Emergency Medicine 38 (2020) 14661469 1467

based peer services targeting high risk OUD patients being discharged from the hospital, and (3) Buprenorphine initiation with referral for on- going care to a network of treatment programs.

Methods

Implementation

Starting in 2014, the state of Maryland undertook an initiative to ex- pand SBIRT into hospital EDs, and to leverage this approach to proac- tively address the opioid crisis. This effort was orchestrated by the Mosaic Group, a healthcare consulting firm responsible for facilitating system-wide implementation of services through a variety of funding streams over the last five years including private foundation grants, local jurisdictional public health funds, state targeted funding and fed- eral funds, including the Substance Abuse and Mental Health Services Administration state SBIRT grants and the State Opioid Response (SOR) grant initiatives. The Mosaic Group piloted SBIRT in three Balti- more hospital EDs starting in 2014 and has grown to 24 hospitals across the state. SBIRT implementation included at least three Peer Recovery Coaches (PRCs) in each ED to deliver BI’s and RT’s across all shifts, and training of ED clinical staff and leadership (Table 1). Mosaic staff worked with community treatment providers to establish a rapid referral net- work in which programs would accept patients referred from the ED within 24 h of discharge. electronic health records (EHRs) at each hos- pital were modified to incorporate Screening tools and checklists for tracking SBIRT services delivered. Deidentified data were downloaded from the EHRs monthly and tracked by the Mosaic Group for quality assurance.

The year one cost to implement the full CHSURP model, which in-

cluded full technical assistance from the Mosaic group, was approxi- mately $330,000 per hospital with 4.0 full time peer recovery coaches. After the first year, the ongoing cost was $200,000 per hospital.

Procedures

Universal screening was conducted in EDs of all participating hospi- tals by nursing staff using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) and one or two questions regarding illicit and prescription drug use [8,9]. The latter enquires “In the last 12 months have you smoked marijuana, used another street drug or used a

prescription pain killer, stimulant, or sedative for a non-medical rea- son?” A score of 7 or more on the AUDIT-C and/or an affirmative answer to the substance use item was considered a positive screen.

Positive screens triggered an EHR icon on the ED tracker board to alert a PRC to assess the patient. In the case of simultaneous positive screens, guidelines were developed to prioritize seeing patients based on their presentation in the following order: 1) opioid and/or alcohol overdoses; 2) opioid positive screens; 3) other Illicit substances (e.g., cocaine); and, 4) alcohol and marijuana use-only. PRCs were trained in motivational interviewing to provide BIs and to assess treat- ment motivation. The PRC developed a plan with the patient, made re- ferral arrangements, and obtained consent to contact the treatment program to confirm attendance. Following the patient’s discharge from the ED, the PRC contacted the treatment provider to confirm follow-up attendance and then recorded in the EHR whether the ap- pointment was kept. Those who attended the initial appointment were counted in the data presented in this report. PRCs followed-up with discharged patients to provide support and inquire about their sat- isfaction with linkages.

Buprenorphine administration initiation procedures

Mosaic staff introduced ED leadership to the buprenorphine ED in- duction protocol developed by D’Onofrio and colleagues [6]. For patients reporting opioid use, the PRC determined patients’ motivation and stage of change, physician assessed DSM-5 criteria for OUD and assessed for the appropriateness of buprenorphine. A nurse conducted the Clinical Opiate Withdrawal Scale , and if the patient had a score >= 7, the physician ordered sublingual administration of 8 mg buprenorphine/naloxone and the PRC made a referral to a community treatment program for same or next-day intake. If the patient’s COWS score was b7 and the patient was discharging, the peer recovery coach made a referral to the community treatment program with the patient’s ED discharge summary.

While implementing SBIRT services as the opioid epidemic unfolded, the Mosaic Group enhanced the SBIRT/PRC model for patients present- ing with an opioid overdose – the Opioid Overdose Survivor’s Outreach Program (OSOP). ED Patients with an opioid overdose were typically unable to be screened by the nursing staff due to their altered mental status. Therefore, nurses were asked to indicate in the patient’s EMR (via a specially incorporated button) that the case was a “suspected

Table 1

Implementation approach.

Service component

Who delivers How completed Role of mosaic facilitators

Screening Nurses or medical assessment

staff screen during triage or nursing assessment

All ED patients are screened with the AUDIT-C and drug screening question(s); The latter branches to specific substances based on initial responses

Worked with each hospital to organize and engage planning team, developed protocols, modified EHR systems, hired and trained PRCs, trained ED staff, provided technical assistance, and reported and monitored data for quality improvement to hospitals

Brief

Intervention

Buprenorphine Initiation

Peer Recovery Coaches (PRCs) employed by the hospitals and stationed in the EDs to deliver BI

Nurses used COWS to assess withdrawal symptoms

PRCs facilitated induction and continued treatment in community

ED physicians diagnosed and inducted new patients

Risk stratification based on screening, PRCs deliver BIs and gauge the need and motivation for continued treatment

Patient is identified as having Opioid withdrawal and motivated for buprenorphine treatment upon release from hospital, assessed by medical team to receive 8 mg Sublingual buprenorphine, and “Fast Tracked” to outpatient buprenorphine provider for continued treatment

Developed and delivered PRC training sessions including: one year of precepting on-site in ED, booster trainings, pharmacotherapy information, and scripts on how to introduce buprenorphine treatment to patients Developed identification and induction procedures within each hospital; trained PRCs, nurses, and physicians; integrated induction process into the EHR

Referral PRC facilitates “Fast Track” referral

PRC identifies most appropriate community provider from pre-arranged list (OTP, IOP/OP, PCP, or psychiatrist), sends discharge summary to community provider, uses discharge summary to obtain order for day 2 buprenorphine induction, and enrolls patient in other services as indicated

Developed “Fast Track” network for each hospital and community by engaging community buprenorphine treatment providers one at a time

Note: ED = emergency department; AUDIT C = alcohol use disorders identification test – consumption; BI=brief intervention; COWS=clinical opiate withdrawal scale; OTP=opioid treatment program; IOP=intensive outpatient; PCP=primary care provider.

1468 L.B. Monico et al. / American Journal of Emergency Medicine 38 (2020) 14661469

overdose.” This automatically triggered an indicator on the ED tracker board to alert the PRC on duty. The PRCs were trained to prioritize meet- ing with such patients as soon as their mental status cleared. Because many overdose survivors decide to leave the ED prior to recommended discharge and are at elevated risk of suffering another overdose, PRCs prioritized Timely interventions focused on rapid harm reduction edu- cation, provision of a Naloxone kit, and recording patient locator and contact information. The PRC also informed the patient that a specially designated OSOP community peer recovery coach would follow-up with them in the next day or two to offer additional support. OSOP pa- tients were followed for 90 days post-ED discharge by a Community PRC to provide follow-up care to engage patients in support services and treatment.

Results

Between July 2014 and November 2018, 1,097,142 ED patients were screened across 23 hospitals throughout MD (Fig. 1). Of those, 17.2%

Linkages to Treatment (n=6,110)

Referrals to Treatment (n=15,961)

Brief Interventions (n=79,899)

Positive Screens (n=188,582)

Universal SBIRT Screening (n=1,097,142

OSOP Referrals (n=1,282)

Suspected Overdoses (n=2,382)

Patients Successfully Engages (n=811)

Referred TO Recovery Support Services (n=350)

Referrals to Treatment (n=329)

Linkages to Treatment (244)

Fig. 1. Cumulative program totals for CSURP – July 2014-November 2018.

Buprenorphine Referrals in the ED (n=950)

Buprenorphine Patients Induced (n=666)

Buprenorphine Referral to Treatment (n=630)

Buprenorphine Linkage to Treatment (n=430)

screened positive for problematic alcohol use or any illicit drug use in the previous 12 months. During this same period, 79,899 brief interven- tions were delivered, and 15,961 referral to outpatient treatment were made, of whom 38.3% were successfully linked to treatment.

A total of 950 patients exhibited opioid withdrawal symptoms and were referred for an evaluation for buprenorphine induction in the ED. Over two-thirds of these patients (70.1%; n = 666) were adminis- tered buprenorphine, and of the patients who started on buprenorphine in the ED, 94.6% (n = 630) accepted a referral to buprenorphine treat- ment in the community, and 64.6% (n = 430) attended their first outpa- tient buprenorphine treatment visit.

A total of 2382 patients presented to the ED with a suspected opioid overdose, 1282 of whom were referred to the OSOP program (53.8%) and 811 (63.2%) were successfully engaged by the PRCs in the ED. Treat- ment referrals were accepted by 329 patients, of whom 244 were di- rectly linked to community-based treatment.

Discussion

In response to alcohol and Substance misuse problems in Maryland, the state’s hospitals and treatment providers have scaled up SBIRT to in- clude targeted services for OUD, including overdose survivor outreach and ED-based buprenorphine initiation with rapid referral. Over the past 4 years, over 1 million patients have been screened, and over 6000 have been linked to community treatment. Among patients started on buprenorphine in the ED, nearly two-thirds attended their first treatment appointment. These data exhibit the possibility of creat- ing a system of care in local communities to link disparate hospitals and treatment organizations to improve continuity of care for ED patients.

SBIRT for problematic alcohol use in EDs is endorsed by national medical organizations [10]. These services can be used as a platform to expand SBIRT to other illicit substances, and to include pharmacother- apy with buprenorphine to address the opioid epidemic. This service model can leave hospitals well-equipped to address emergent sub- stance use epidemics. Similar efforts elsewhere should be evaluated and longer-term follow-up of patients receiving linkage to community care should be conducted.

Limitations

This report has several limitations. First, it was not always possible for the coaches to see all ED patients who screened positive because at times there were multiple such patients in the ED simultaneously. Other times, the PRC assigned to the shift was absent due to vacation, holidays, or illness. The PRCs did not conduct a diagnostic assessment of the patients. The number of patients that declined to speak with a PRC was not tracked. Not all patients who received a BI needed or wanted a referral to treatment. Finally, it was not possible to follow pa- tients to determine their outcomes.

Conclusions

This analysis supports the scalability of SBIRT in hospital EDs and presents an implementation model that can be replicated in EDs nation- wide. Future work should track patient outcomes in terms of continuing engagement in treatment, reduction in alcohol and substance use and their associated problems, including overdose.

CRediT authorship contribution statement Laura B. Monico: Conceptualization, Writing – original draft, Visual-

ization. Marla Oros: Data curation, Writing – review & editing, Project

administration, Funding acquisition. Sadie Smith: Data curation, Writing – review & editing, Supervision. Shannon Gwin Mitchell: Writing – review & editing. Jan Gryczynski: Writing – review & editing. Robert Schwartz: Conceptualization, Writing – review & editing.

L.B. Monico et al. / American Journal of Emergency Medicine 38 (2020) 14661469 1469

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