ABSTRACT
BACKGROUND: Despite rising hospitalizations for opioid use disorder (OUD), rates of inpatient medications for OUD (MOUD) initiation are low. Addiction consult services (ACSs) facilitate inpatient MOUD initiation and linkage to post-discharge MOUD, but few studies have rigorously examined ACS OUD outcomes. OBJECTIVE: To determine the association between ACS consultation and inpatient MOUD initiation, discharge MOUD provision, and post-discharge MOUD linkage. DESIGN: Retrospective study comparing admissions that received an ACS consult and propensity score-matched historical control admissions. SUBJECTS: One hundred admissions with an OUD-related diagnosis, of patients not currently receiving MOUD who received an ACS consult, and 100 matched historical controls. INTERVENTION: Consultation from an interprofessional ACS offering expertise in MOUD initiation and linkage to post-discharge MOUD. MAIN MEASURES: The primary outcome was inpatient MOUD initiation (methadone or buprenorphine). Secondary outcomes were inpatient buprenorphine initiation, inpatient methadone initiation, discharge prescription for buprenorphine, linkage to post-discharge MOUD (buprenorphine prescription within 60 days and new methadone administration at a methadone program within 30 days after discharge), patient-directed discharge, 30-day readmission, and 30-day emergency department (ED) visit. KEY RESULTS: Among 200 admissions with an OUD-related diagnosis, those that received an ACS consultation were significantly more likely to have inpatient MOUD initiation (OR 2.57 [CI 1.44-4.61]), inpatient buprenorphine initiation (OR 5.50 [2.14-14.15]), a discharge prescription for buprenorphine (OR 17.22 [3.94-75.13]), a buprenorphine prescription within 60 days (22.0% vs. 0.0%, p < 0.001; of those with inpatient buprenorphine initiation: 84.6% vs. 0.0%), and new methadone administration at a methadone program within 30 days after discharge (7.0% vs. 0.0%, p = 0.007; of those with inpatient methadone initiation: 19.4% vs. 0.0%). There were no significant differences in other secondary outcomes. CONCLUSIONS: There was a strong association between ACS consultation and inpatient MOUD initiation and linkage to post-discharge MOUD. ACSs promote the delivery of evidence-based care for patients with OUD.
ABSTRACT
Introduction: Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions. Methods: This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience. Results: Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively). Conclusion: Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.