A Retrospective Evaluation of Adjunctive Phenobarbital vs. Benzodiazepine Alone for the Treatment of Moderate Alcohol Withdrawal in the Emergency Department.

BACKGROUND: Phenobarbital has been used in the emergency department (ED) as both a primary and adjunctive medication for alcohol withdrawal, but previous studies evaluating its impact on patient outcomes are limited by heterogenous symptom severity. OBJECTIVES: We compared the clinical outcomes of ED patients with moderate alcohol withdrawal who received phenobarbital, with or without benzodiazepines, with patients who received benzodiazepine treatment alone. METHODS: This is a retrospective cohort study conducted at a single academic medical center utilizing chart review of ED patients with moderate alcohol withdrawal between 2015 and 2020. Patient encounters were classified into two treatment categories based on medication treatment: phenobarbital alone or in combination with benzodiazepines vs. benzodiazepines alone. Chi-square test or Fisher's exact was used to analyze categorical variables and the Student's t-test for continuous data. RESULTS: Among the 287 encounters that met inclusion criteria, 100 received phenobarbital, compared with 187 that received benzodiazepines alone. Patients who received phenobarbital were provided significantly more lorazepam equivalents. There was a significant difference in the percentage of patient encounters that required admission to the hospital in the phenobarbital cohort compared with the benzodiazepine cohort (75% vs. 43.3%, p < 0.001). However, there was no difference in admission level of care to the floor (51.2% vs. 52.0%), stepdown (33.8% vs. 28%), or intensive care unit (15% vs. 20%), respectively. CONCLUSIONS: Patients who received phenobarbital for moderate alcohol withdrawal were more likely to be admitted to the hospital, but there was no difference in admission level of care when compared with patients who received benzodiazepines alone. Patients who received phenobarbital were provided greater lorazepam equivalents in the ED.

A qualitative assessment of emergency physicians' experiences with robust emergency department buprenorphine bridge programs.

OBJECTIVES: Emergency departments (EDs) are a critical point of entry into treatment for patients struggling with opioid use disorder (OUD). When initiated in the ED, buprenorphine is associated with increased addiction treatment engagement at 30 days when initiated. Despite this association, it has had slow adoption. The barriers to ED buprenorphine utilization are well documented; however, the benefits of prescribing buprenorphine for emergency physicians (EPs) have not been explored. This study utilized semistructured interviews to explore and understand how EPs perceive their experiences working in EDs that have successfully implemented ED bridge programs (EDBPs) for patients with OUD. METHODS: Semistructured interviews were conducted with EPs from four geographically diverse academic hospitals with established EDBPs. Interviews were recorded and transcribed, and emergent themes were identified using codebook thematic analysis. Analysis credibility and transparency were confirmed with peer debriefing. RESULTS: Twenty-two interviews were conducted across the four sites. Three key themes were constructed during the analyses: (1) provided EPs agency; (2) transformed EPs' emotions, attitudes, and behaviors related to treating patients with OUD; and (3) improved EPs' professional quality of life. CONCLUSIONS: Participants in this study reported several common themes related to participation in their hospital's BP. Overall our results suggest that physicians who participate in EDBPs may feel a renewed sense of fulfillment and purpose in their personal and professional lives. These positive changes may lead to increased job satisfaction in hospitals that have successfully launched EDBP.

Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use.

STUDY OBJECTIVE(S): To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. METHODS: Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. RESULTS: The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). CONCLUSION: The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.

Impact of Statewide Statute Limiting Days' Supply to Opioid-Naive Patients.

INTRODUCTION: To address the ongoing opioid crisis, states use policy enactment to restrict prescribing by licensed healthcare providers and mandate the use of Prescription Drug Monitoring Programs. There have been mixed results regarding the effectiveness of such state policies. The purpose of this study is to evaluate the impact of Colorado Senate Bill 18-022, which limits opioid prescriptions to ≤7-day supply among patients without an opioid prescription in the previous year (i.e., are opioid naive). METHODS: This is a retrospective interrupted time-series analysis of opioid prescribing to evaluate the weekly percentage of opioid prescriptions consistent with statutory limits for ≤7-day supply among opioid-naive patients before and after enactment using Prescription Drug Monitoring Programs data from May 21, 2017 to May 25, 2019. Statistical analysis was performed in 2021-2022. RESULTS: The weekly percentage of opioid prescriptions ≤7-day supply increased by an average of 0.12% per week (p<0.0001) from 79.7% to 87.4% in the week before enactment. The week after enactment, the average increased by 0.2% (p=0.67). The year after enactment, the average weekly percentage change was 0.07% per week, a 0.05% decrease (p=0.01). CONCLUSIONS: Statutory limits on days' supply among opioid-naive patients had little impact on opioid prescribing in Colorado. Legislating limits on opioid prescribing should be evaluated using Prescription Drug Monitoring Program data and considered for deimplementation when not impactful.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department.

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms. We present those measures here, alongside initial performance data on those measures from a sample of 370 nationwide community EDs participating in the 2019 E-QUAL collaborative. Measures include proportion of opioid administration in the ED, proportion of alternatives to opioids as first-line treatment, proportion of opioid prescription, opioid pill count per prescription, and patient medication safety education among ED visits for atraumatic back pain, dental pain, or headache. The proportion of benzodiazepine and opioid coprescribing for ED visits for atraumatic back pain was also evaluated. This project developed and effectively implemented a collection of 6 potential measures to evaluate opioid analgesic prescribing across a national sample of community EDs, representing the first feasibility assessment of opioid prescribing-related measures from rural and community EDs.

Targeted messaging to improve the adoption of clinical decision support for prescription drug monitoring program use.

Clinical decision support (CDS) can prevent medical errors and improve patient outcomes. Electronic health record (EHR)-based CDS, designed to facilitate prescription drug monitoring program (PDMP) review, has reduced inappropriate opioid prescribing. However, the pooled effectiveness of CDS has exhibited substantial heterogeneity and current literature does not adequately detail why certain CDS are more successful than others. Clinicians regularly override CDS, limiting its impact. No studies recommend how to help nonadopters recognize and recover from CDS misuse. We hypothesized that a targeted educational intervention would improve CDS adoption and effectiveness for nonadopters. Over 10 months, we identified 478 providers consistently overriding CDS (nonadopters) and sent each up to 3 educational message(s) via email or EHR-based chat. One hundred sixty-one (34%) nonadopters stopped consistently overriding CDS and started reviewing the PDMP after contact. We concluded that targeted messaging is a low-resource way to disseminate CDS education and improve CDS adoption and best practice delivery.

Implementation strategies to address the determinants of adoption, implementation, and maintenance of a clinical decision support tool for emergency department buprenorphine initiation: a qualitative study.

BACKGROUND: Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations. METHODS: We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns. RESULTS: Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine. CONCLUSION: The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine.

Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions.

Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.

User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial.

OBJECTIVE: To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN: Pragmatic cluster randomized controlled trial (EMBED). SETTING: 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS: 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION: A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES: Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS: 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS: User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov NCT03658642.

Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems.

STUDY OBJECTIVE: People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. METHODS: Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. RESULTS: Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. CONCLUSION: Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Provider Reactions to Opioid-Prescribing Report Cards.

OBJECTIVE: To evaluate prescribers' reactions and self-reported intentions to change prescribing behavior in response to opioid-prescribing report cards. DESIGN: We surveyed a sample of licensed prescribers in the state of Colorado registered with the state's prescription drug monitoring program (PDMP). SETTING: In 2018, Colorado disseminated tailored opioid-prescribing report cards to increase use of the PDMP and improve opioid prescribing. Report cards reflected individual prescribing history and compared individuals with an aggregate of others in the same specialty. Surveys were sent to approximately 29 000 prescribers registered with the PDMP 12 weeks after report card distribution. If respondents were not sent a report card, they were shown a sample report. Respondents were asked about their perceptions of the usefulness of the information and intentions to change their prescribing. PARTICIPANTS: A total of 3784 prescribers responded to the survey. MAIN OUTCOME MEASURES: Respondents were asked about their attitudes and reactions to an opioid-prescribing report card. Answers were given in the form of a 5-point Likert scale or multiple-choice questions. RESULTS: Of those who responded, 53.6% were male and nearly half (49.5%) had spent more than 20 years in practice. Among prescribers who recalled receiving a report card, most felt the reports were easy to understand (87.4%) and provided new information (82.8%). Two-thirds of prescribers who saw their reports felt the information accurately reflected their prescribing practices. Overall, 40.0% reported they planned to change their prescribing behaviors as a result of the information provided. The most useful metrics identified by prescribers were the number of patients with multiple providers and the number of patients receiving dangerous combination therapy. CONCLUSIONS: Overall, perceptions of the usefulness and accuracy of the report cards were positive. Understanding how the reports are perceived is a key factor to their use and influence. Further tailoring of the report to prescribers of different specialties and experience may enhance the effectiveness of the report cards.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

Physician attitudes on buprenorphine induction in the emergency department: results from a multistate survey.

STUDY OBJECTIVE: Emergency Departments (ED) are rapidly becoming an important location for initiation of buprenorphine (EDBUP) for the treatment of opioid use disorder (OUD). Previous investigations of emergency medicine physicians' perceived barriers and attitudes toward EDBUP exclusively sampled from urban, academic-affiliated physicians. We administered a multistate survey to an institutionally and geographically diverse collection of emergency medicine physicians to better understand the professional opinions of EDBUP implementation across a variety of practice settings. METHODS: This cross-sectional survey study used an online survey instrument to convenience sample emergency medicine physicians. In order to sample from various practice environments, participants were identified from (1) statewide ACEP chapters and (2) Facebook groups exclusive to emergency medicine physicians. The survey explored physicians' attitudes of EDBUP adoption and the perceived barriers to doing so. RESULTS: 162 emergency medicine physicians completed the survey. 76% of respondents agreed that emergency medicine physicians should offer EDBUP in the treatment of OUD. When stratified by practice setting and X-waiver status, 96% of X-waivered physicians, 73% of academic physicians, 49% of non-academic physicians, and 34% of non-X-waivered physicians felt comfortable initiating EDBUP. Lack of access to outpatient MOUD referral was the most frequently cited barrier to EDBUP across all practice settings. CONCLUSIONS: An institutionally and geographically diverse group of emergency medicine physicians endorsed substantial support for EDBUP. Emergency medicine physicians practicing in different clinical environments endorsed similar barriers to EDBUP implementation.

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US.

Importance: As coronavirus disease 2019 (COVID-19) spread throughout the US in the early months of 2020, acute care delivery changed to accommodate an influx of patients with a highly contagious infection about which little was known. Objective: To examine trends in emergency department (ED) visits and visits that led to hospitalizations covering a 4-month period leading up to and during the COVID-19 outbreak in the US. Design, Setting, and Participants: This retrospective, observational, cross-sectional study of 24 EDs in 5 large health care systems in Colorado (n = 4), Connecticut (n = 5), Massachusetts (n = 5), New York (n = 5), and North Carolina (n = 5) examined daily ED visit and hospital admission rates from January 1 to April 30, 2020, in relation to national and the 5 states' COVID-19 case counts. Exposures: Time (day) as a continuous variable. Main Outcomes and Measures: Daily counts of ED visits, hospital admissions, and COVID-19 cases. Results: A total of 24 EDs were studied. The annual ED volume before the COVID-19 pandemic ranged from 13 000 to 115 000 visits per year; the decrease in ED visits ranged from 41.5% in Colorado to 63.5% in New York. The weeks with the most rapid rates of decrease in visits were in March 2020, which corresponded with national public health messaging about COVID-19. Hospital admission rates from the ED were stable until new COVID-19 case rates began to increase locally; the largest relative increase in admission rates was 149.0% in New York, followed by 51.7% in Massachusetts, 36.2% in Connecticut, 29.4% in Colorado, and 22.0% in North Carolina. Conclusions and Relevance: From January through April 2020, as the COVID-19 pandemic intensified in the US, temporal associations were observed with a decrease in ED visits and an increase in hospital admission rates in 5 health care systems in 5 states. These findings suggest that practitioners and public health officials should emphasize the importance of visiting the ED during the COVID-19 pandemic for serious symptoms, illnesses, and injuries that cannot be managed in other settings.

Self-Reported Opioid Use and Driving Outcomes among Older Adults: The AAA LongROAD Study.

BACKGROUND: Opioid medications are important therapeutic options to mitigate the harmful effects of pain but can also impair driving ability. We sought to explore opioid use, pain levels, and driving experiences among older drivers. METHODS: Cognitively intact drivers ages 65 to 79 years were recruited for the multisite AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2990). This cross-sectional analysis used data from the baseline questionnaire and "brown-bag" medication review. RESULTS: Among LongROAD participants (47% male, 88% white, 41% aged 65 to 69 years), 169 (5.7%) reported currently taking an opioid, with a median daily dose of 20 morphine milligram equivalents. Participants did not differ significantly in opioid use by age, gender, race, or ethnicity (P > .05). After adjustment for age, gender, race and ethnicity, participants who were taking opioids (vs not) were significantly more likely to report self-regulated driving reduction and reduced driving ability. However, these effects became nonsignificant when hospitalization, impaired physical function and other factors associated with opioid use were controlled. CONCLUSIONS: In this study from a large, geographically diverse sample of older adults, there was an association between opioid use and several self-reported measures of driving behavior and ability. However, future work should clarify the effects on driving of opioid use from the effects of the painful medical conditions for which the opioids are being taken. Clinicians should continue to discuss the risks and benefits of opioid medications with patients, including risks related to driving safety.

Association of Emergency Department Opioid Administration With Ongoing Opioid Use: A Retrospective Cohort Study of Patients With Back Pain.

OBJECTIVES: Opioids are commonly administered in the emergency department (ED) and prescribed for the treatment of back pain. It is important to understand the unintended consequences of this approach to inform treatment decisions and the consideration of alternative treatments. Recent evidence has shown that ED opioid prescriptions are associated with future opioid use. The objective of this study was to measure the association of opioid administration in the ED to patients treated for back pain with future opioid use. METHODS: This is a retrospective study of opioid-naïve adults discharged from the ED with a diagnosis of back pain. Patients were stratified by opioid therapy (none, ED administration only, prescription only, or ED administration + prescription). Relative risks of ongoing opioid use (filling >90-day supply in 180 days following ED visit as documented in the prescription drug monitoring program) were calculated for each opioid-therapy group and compared to the no-opioid group. RESULTS: We identified 24,487 opioid naïve back pain patients. The median age was 38 years, 55% were female, and 56% were non-Hispanic white. A total of 41% received no opioid, 10% were only administered an opioid in the ED, 18% only received a prescription, and 31% received an opioid in the ED + prescription. The adjusted relative risks of ongoing use compared to the no opioid group were as follows: ED only 1.9, prescription only 2.1, and ED + prescription 2.3. The increased risk persisted for other definitions of ongoing use and after adjustment for baseline pain scores. CONCLUSIONS: For opioid-naïve patients with back pain, both administration of an opioid in the ED and opioid prescriptions are associated with a doubling of the risk of ongoing opioid use compared to patients not treated with opioids. This supports the consideration of minimizing exposure to opioids while treating back pain in the ED.

Progress Report on EMBED: A Pragmatic Trial of User-Centered Clinical Decision Support to Implement EMergency Department-Initiated BuprenorphinE for Opioid Use Disorder.

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.