A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department.

STUDY OBJECTIVE: Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS: We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS: Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS: Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.

Assault Injury and Community Violence.

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

Early emergency department experience with 7-day extended-release injectable buprenorphine for opioid use disorder.

As the opioid overdose epidemic escalates, there is an urgent need for treatment innovations to address both patient and clinician barriers when initiating buprenorphine in the emergency department (ED). These include insurance status, logistical challenges such as the ability to fill a prescription and transportation, concerns regarding diversion, and availability of urgent referral sites. Extended-release buprenorphine (XR-BUP) preparations such as a new 7-day injectable could potentially solve some of these issues. We describe the pharmacokinetics of a new 7-day XR-BUP formulation and the feasibility of its use in the ED setting. We report our early experiences with this medication (investigational drug CAM2038), in the context of an ongoing clinical trial entitled Emergency Department-Initiated BUP VAlidaTION (ED INNOVATION), to inform emergency clinicians as they consider incorporating this medication into their practice. The medication was approved by the European Medicines Agency in 2018 and the U.S. Food and Drug Administration in 2023 for those 18 years or older for the treatment of moderate to severe opioid use disorder (OUD). We report our experience with approximately 800 ED patients with OUD who received the 7-day XR-BUP preparation in the ED between June 2020 and July 2023.

Perspectives on and experiences of emergency department-initiated buprenorphine among clinical pharmacists: A multi-site qualitative study.

INTRODUCTION: Clinical pharmacists are well positioned to enhance efforts to promote emergency department (ED)-initiated buprenorphine to treat opioid use disorder (OUD). Among clinical pharmacists in urban EDs, we sought to characterize barriers and facilitators for ED-initiated buprenorphine to inform future implementation efforts and enhance access to this highly effective OUD treatment. METHODS: This study was conducted as a part of Project ED Health (CTN-0069, NCT03023930), a multisite effectiveness-implementation study aimed at promoting ED-initiated buprenorphine that was conducted between April 2017 and July 2020. Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) framework to assess perspectives on the relationship between 3 elements: evidence for buprenorphine, the ED context, and facilitation needs to promote ED-initiated buprenorphine. The study used an iterative coding process to identify overlapping themes within these 3 domains. RESULTS: The study conducted eight focus groups/interviews across four geographically disparate EDs with 15 pharmacist participants. We identified six themes. Themes related to evidence included (1) varied levels of comfort and experience among pharmacists with ED-initiated buprenorphine that increased over time and (2) a perception that patients with OUD have unique challenges that require guidance to optimize ED care. With regards to context, clinical pharmacists identified: (3) their ability to clarify scope of ED care in the context of unique pharmacology, formulations, and regulations of buprenorphine to ED staff, and that (4) their presence promotes successful program implementation and quality improvement. Participants identified facilitation needs including: (5) training to promote practice change and (6) ways to leverage already existing pharmacy resources outside of the ED. CONCLUSION: Clinical pharmacists play a unique and critical role in the efforts to promote ED-initiated buprenorphine. We identified 6 themes that can inform pharmacist-specific interventions that could aid in the successful implementation of this practice.

Perspectives of Clinicians and Staff at Community-Based Opioid Use Disorder Treatment Settings on Linkages With Emergency Department-Initiated Buprenorphine Programs.

Importance: An increasing number of emergency departments (EDs) are initiating buprenorphine for opioid use disorder (OUD) and linking patients to ongoing community-based treatment, yet community-based clinician and staff perspectives regarding this practice have not been characterized. Objective: To explore perspectives and experiences regarding ED-initiated buprenorphine among community-based clinicians and staff in geographically distinct regions. Design, Setting, and Participants: This qualitative study reports findings from Project ED Health, a hybrid type 3 effectiveness-implementation study designed to evaluate the impact of implementation facilitation on ED-initiated buprenorphine with referral to ongoing medication treatment. Clinicians and staff from community-based treatment programs were identified by urban academic EDs as potential referral sites for ongoing OUD treatment in 4 cities across the US in a formative evaluation as having the capability to continue medication treatment. Focus groups were held from April 1, 2018, to January 11, 2019, to examine community OUD treatment clinician and staff perspectives on accepting patients who have received ED-initiated buprenorphine. Data were analyzed from August 2020 to August 2022. Main Outcomes and Measures: Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework, focusing on domains including evidence, context, and facilitation. Results: A total of 103 individuals (mean [SD] age, 45.3 [12.0] years; 76 female and 64 White) participated in 14 focus groups (groups ranged from 3-22 participants). Participants shared negative attitudes toward buprenorphine and variable attitudes toward ED-initiated buprenorphine. Prominent barriers included the community site treatment capacity and structure as well as payment and regulatory barriers. Perceived factors that could facilitate this model included additional substance use disorder training for ED staff, referrals and communication, greater inclusion of peer navigators, and addressing sociostructural marginalization that patients faced. Conclusions and Relevance: In this study of community-based clinicians and staff positioned to deliver OUD treatment, participants reported many barriers to successful linkages for patients who received ED-initiated buprenorphine. Strategies to improve these linkages included educating communities and programs, modeling low-barrier philosophies, and using additional staff trained in addiction as resources to improve transitions from EDs to community partners.

National Institute on Drug Abuse Clinical Trials Network Meeting Report: Advancing Emergency Department Initiation of Buprenorphine for Opioid Use Disorder.

Opioid use disorder and opioid overdose deaths are a major public health crisis, yet highly effective evidence-based treatments are available that reduce morbidity and mortality. One such treatment, buprenorphine, can be initiated in the emergency department (ED). Despite evidence of efficacy and effectiveness for ED-initiated buprenorphine, universal uptake remains elusive. On November 15 and 16, 2021, the National Institute on Drug Abuse Clinical Trials Network convened a meeting of partners, experts, and federal officers to identify research priorities and knowledge gaps for ED-initiated buprenorphine. Meeting participants identified research and knowledge gaps in 8 categories, including ED staff and peer-based interventions; out-of-hospital buprenorphine initiation; buprenorphine dosing and formulations; linkage to care; strategies for scaling ED-initiated buprenorphine; the effect of ancillary technology-based interventions; quality measures; and economic considerations. Additional research and implementation strategies are needed to enhance adoption into standard emergency care and improve patient outcomes.

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder.

Importance: Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused. Objective: To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy. Design, Setting, and Participants: This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022. Exposure: A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback. Main Outcomes and Measures: The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed. Results: A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits). Conclusions and Relevance: In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine. Trial Registration: ClinicalTrials.gov Identifier: NCT03023930.

Revisiting "Excited Delirium": Does the Diagnosis Reflect and Promote Racial Bias?

INTRODUCTION: "Excited delirium" (ExD) is purported to represent a certain type of agitated state that can lead to unexpected death. The 2009 "White Paper Report on Excited Delirium Syndrome," authored by the American College of Emergency Medicine (ACEP) Excited Delirium Task Force, continues to play a pivotal role in defining ExD. Since that report was produced, there has been an increasing appreciation that the label has been applied more often to Black people. METHODS: Our aim was to analyze the language of the 2009 report, the role of potential stereotypes, and the mechanisms that may potentially encourage bias. RESULTS: Our evaluation of the diagnostic criteria for ExD proposed in the 2009 report shows that it relies on persistent racial stereotypes: eg, unusual strength, decreased sensitivity to pain, and bizarre behavior. Research indicates that use of such stereotypes could encourage biased diagnosis and treatment. CONCLUSION: We suggest that the emergency medicine community avoid use of the concept ExD and that ACEP withdraw implicit or explicit support of the report.

United States Emergency Department Screening for Drug Use Among Assault-Injured Individuals: A Systematic Review.

INTRODUCTION: The clinical model of screening, providing a brief psychosocial and/or pharmacological intervention, and directly referring patients to treatment (SBIRT) is a compelling model to address drug use among assault-injured individuals in the busy emergency department (ED) setting. Our objective in this study was to examine the current literature and determine ED-based strategies that have been reported that screen, directly refer to drug mis-use/addiction specialized treatment services, or initiate addiction treatment among individuals injured by non-partner assault in the United States. METHODS: We conducted a systematic review of ED-based studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. OVID, MEDLINE, OVID Embase, OVID AMED, Web of Science-Core Collection, Cochrane CENTRAL, and CINAHL were systematically searched using keywords and Medical Subject Heading terms. Studies were excluded if they only involved intimate partner assault-injury, tobacco, or alcohol use. We categorized ED-based strategies as screening, direct referral, or treatment initiation. RESULTS: Of the 2,076 non-duplicated studies identified, we included 26 full-text articles in the final analysis. Fourteen studies were cross-sectional, 11 were cohort, and one was case-control in design. The most common drug use screening instrument used was the National Institute on Drug Abuse Quick Screen Question. Cannabis was the most common drug detected upon screening. CONCLUSION: Drug use, while highly prevalent, is a modifiable risk factor for non-partner assault-injury. The paucity of scientific studies is evidence for the need to intentionally address this area that remains a major challenge for the public's health. Future research is needed to evaluate ED-based interventions for drug use in this population.

Models for Implementing Emergency Department-Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers.

There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder.

Importance: Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment. Objective: To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED. Design, Setting, and Participants: This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019. Main Outcomes and Measures: Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements. Results: A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training. Conclusions and Relevance: In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.

Trauma-Informed Acute Care of Patients With Violence-Related Injury.

Violently-injured individuals presenting to the emergency department (ED) have an elevated risk of repeat injury after being discharged from acute care settings and a high rate of unaddressed mental health and social needs. While there is a growing body of programmatic interventions to address these needs, including hospital-based violence intervention programs, there is a lack of data regarding physician perspectives of current practice for this patient population. Understanding current practice is critical for integrating new programs into workflow and developing evidence-based medical education to improve care. The aim of this study is to elucidate current trauma-informed care practices of emergency medicine and general surgery trainee physicians to inform future curriculum development surrounding care of violently injured patients. In this study, emergency medicine and surgical trainees with at least one year of residency experience participated in simulation-primed interviews in pairs or small groups. Interviews garnered perspectives on the physician role in treating violently injured youth, using simulation as a priming event focused on previously known patient concerns. Qualitative themes that emerged were participants (1) perceived their role as managing medical/surgical concerns and seek others to build trust and manage psychosocial and legal concerns, (2) had a high level of knowledge of ED stressors and de-escalation strategies, (3) perceived that patient distrust can negatively impact their ability to provide care, and (4) perceived that law enforcement can negatively impact care and are sometimes uncertain about how to interact with law enforcement. These findings support that medical education for providers should focus on medicolegal issues, particularly managing law enforcement presence in the ED, structural and interpersonal causes of distrust of medical providers and the medical system, and addressing postdischarge mental health and social needs.

The design and conduct of a randomized clinical trial comparing emergency department initiation of sublingual versus a 7-day extended-release injection formulation of buprenorphine for opioid use disorder: Project ED Innovation.

ED-INNOVATION (Emergency Department-INitiated bupreNOrphine VAlidaTION) is a Hybrid Type-1 Implementation-Effectiveness multisite emergency department (ED) study funded through The Helping to End Addiction Long-termSM Initiative, or NIH HEAL InitiativeSM efforts to increase access to medications for opioid use disorder (OUD). We use components of Implementation Facilitation to enhance adoption of ED-initiated buprenorphine (BUP) at approximately 30 sites. Subsequently we compare the effectiveness of two BUP formulations, sublingual (SL-BUP) and 7-day extended-release injectable (CAM2038, XR-BUP) in a randomized clinical trial (RCT) of approximately 2000 patients with OUD on the primary outcome of engagement in formal addiction treatment at 7 days. Secondary outcomes assessed at 7 and 30 days include self-reported opioid use, craving and satisfaction, health service utilization, overdose events, and engagement in formal addiction treatment (30 days) and receipt of medications for OUD (at 7 and 30 days). A sample size of 1000 per group provides 90% power at the 2-sided significance level to detect a difference in the primary outcome of 8% and accommodates a 15% dropout rate. We will compare the cost effectiveness of the two treatments on the primary outcome using the incremental cost-effectiveness ratio. We will also conduct an ancillary study in approximately 75 patients experiencing minimal to no opioid withdrawal who will undergo XR-BUP initiation. If the ancillary study demonstrates safety, we will expand the eligibility criteria for the RCT to include individuals with minimal to no opioid withdrawal. The results of these studies will inform implementation of ED-initiated BUP in diverse EDs which has the potential to improve treatment access.

Emergency department patients with untreated opioid use disorder: A comparison of those seeking versus not seeking referral to substance use treatment.

BACKGROUND Little is known regarding the sociodemographic and clinical characteristics of emergency department (ED) patients with untreated opioid use disorder (OUD) and the relationship of those characteristics with whether they were seeking a referral to substance use treatment at the time of their ED visit. METHODS Using data collected from 2/2017-1/2019 from participants enrolled in Project ED Health (CTN-0069), we conducted a cross-sectional analysis of patients with untreated moderate to severe OUD presenting to one of four EDs in Baltimore, New York City, Cincinnati, or Seattle. Sociodemographic and clinical correlates, and International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes related to opioid withdrawal, injection-related infection, other substance use, overdose, and OUD of those seeking and not seeking a referral to substance use treatment on presentation were compared using univariate analyses. RESULTS Among 394 study participants, 15.2 % (60/394) came to the ED seeking a referral to substance use treatment. No differences in age, gender, education, health insurance status or housing stability were detected between those seeking and not seeking referral to substance use treatment. Those seeking a referral to substance use treatment were less likely to have urine toxicology testing positive for amphetamine [17 % (10/60) vs 31 % (104/334), p = 0.023] and methamphetamine [23 % (14/60) vs 40 % (132/334), p = 0.017] compared to those not seeking a referral. CONCLUSION Most patients with untreated OUD seen in the EDs were not seeking a referral to substance use treatment. Active identification, treatment initiation, and coding may improve ED efforts to address untreated OUD.

Use of Amphetamine-Type Stimulants Among Emergency Department Patients With Untreated Opioid Use Disorder.

STUDY OBJECTIVE: Concurrent use of amphetamine-type stimulants among individuals with opioid use disorder can exacerbate social and medical harms, including overdose risk. The study evaluated rates of amphetamine-type stimulant use among patients with untreated opioid use disorder presenting at emergency departments in Baltimore, MD; New York, NY; Cincinnati, OH; and Seattle, WA. METHODS: Emergency department (ED) patients with untreated opioid use disorder (N=396) and enrolled between February 2017 and January 2019 in a multisite hybrid type III implementation science study were evaluated for concurrent amphetamine-type stimulant use. Individuals with urine tests positive for methamphetamine, amphetamine, or both were compared with amphetamine-type stimulant-negative patients. RESULTS: Overall, 38% of patients (150/396) were amphetamine-type stimulant positive; none reported receiving prescribed amphetamine or methamphetamine medications. Amphetamine-type stimulant-positive versus -negative patients were younger: mean age was 36 years (SD 10 years) versus 40 years (SD 12 years), 69% (104/150) versus 46% (114/246) were white, 65% (98/150) versus 54% (132/246) were unemployed, 67% (101/150) versus 49 (121/246) had unstable housing, 47% (71/150) versus 25% (61/245) reported an incarceration during 1 year before study admission, 60% (77/128) versus 45% (87/195) were hepatitis C positive, 79% (118/150) versus 47% (115/245) reported drug injection during 1 month before the study admission, and 42% (62/149) versus 29% (70/244) presented to the ED for an injury. Lower proportions of amphetamine-type stimulant-positive patients had cocaine-positive urine test results (33% [50/150] versus 52% [129/246]) and reported seeking treatment for substance use problems as a reason for their ED visit (10% [14/148] versus 19% [46/246]). All comparisons were statistically significant at P<.05 with the false discovery rate correction. CONCLUSION: Amphetamine-type stimulant use among ED patients with untreated opioid use disorder was associated with distinct sociodemographic, social, and health factors. Improved ED-based screening, intervention, and referral protocols for patients with opioid use disorder and amphetamine-type stimulant use are needed.

Barriers and Facilitators to Clinician Readiness to Provide Emergency Department-Initiated Buprenorphine.

Importance: Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians. Objective: To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types. Design, Setting, and Participants: Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020. Main Outcomes and Measures: Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively. Results: Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care. Conclusions and Relevance: Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.

Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study.

BACKGROUND: Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE: To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN: Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS: Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES: Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS: There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS: Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.

Physicians on the Frontlines: Understanding the Lived Experience of Physicians Working in Communities That Experienced a Mass Casualty Shooting.

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events."