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Providing buprenorphine in emergency departments

April 11, 2023

Jason Brian Gibbons is a postdoctoral fellow in the Department of Health Policy & Management at the Johns Hopkins School of Public Health. He is currently working on a multidisciplinary team evaluating state-level opioid policy reform as a part of the Bloomberg Overdose Prevention Initiative. We talked to him to better understand one of the strategies to increase access to evidence-based treatment: providing buprenorphine in emergency rooms. 

Why is providing buprenorphine in emergency departments important? 

Starting patients on buprenorphine in emergency departments, and referring them for follow-up care, is highly important because EDs commonly treat individuals who have experienced an overdose and are at the greatest risk of subsequent overdoses. By providing these people with gold-standard treatment for opioid use disorder, their risk of future overdoses declines dramatically. These individuals are also more likely to engage and continue with outpatient behavioral health care services after starting buprenorphine treatment, setting them on a path to long-term recovery.

In a sense, the ED is the frontline workforce in the overdose epidemic, and transitioning from treating the immediate symptoms of overdose to treating the underlying opioid use disorder is a natural progression in their role.

What do we know about how many hospitals do this, and why or why not?

We are still in a relatively nascent period of ramping up ED activity in buprenorphine initiation and prescribing. States are creating new programs to encourage hospitals to begin buprenorphine initiation and refer people to outpatient care, which have led to some early successes.

Hospitals are generally philosophically aligned with expanding buprenorphine treatment due to its potential to improve population health, but there remain some key barriers. For example, cost, administrative burden, and stigma among providers have all been important barriers to wider adoption. Expanding treatment in EDs requires updating electronic health record systems, coordinating with hospital pharmacies to stock buprenorphine, engaging with providers to ensure they are actively prescribing, and training providers to treat people with opioid use disorders equitably. Even with careful coordination, a lot of time, energy, and resources are needed to begin a buprenorphine initiation and referral program. This can be especially difficult for less-well-resourced hospitals. Many patients with opioid use disorders also lack insurance, which means not all buprenorphine activities will end up getting reimbursed. While savings may be generated by reducing the number of overdose cases, this calculus isn’t always easy for hospital C-suites.

Tell us about the project in Pennsylvania that you helped evaluate. 

Our study evaluated a recent Pennsylvania Department of Human Services initiative, called the Opioid Hospital Quality Improvement Program (O-HQIP). The program was created to increase buprenorphine inductions and referrals for Medicaid patients with opioid use disorders in EDs in Pennsylvania; about 75% of all hospitals in the state participated.

O-HQIP included two phases. In the first phase, O-HQIP provided payments to hospitals that agreed to implement 1 or more of 4 clinical pathways: (1) ED initiation of buprenorphine, (2) warm handoff to community treatment resources, (3) dedicated protocols for pregnant people with OUD, and (4) hospitalization for induction of buprenorphine.

In the second phase, all hospitals received payments based on the number of Medicaid enrollees that were connected to treatment within 7 days of discharge for an OUD-related cause (e.g., overdose). Our study looked at what happened to buprenorphine initiations and warm-handoffs for follow-up treatment from before to after the first two phases.

What did your research find?

Our study ultimately found a 2.6 percentage point increase in prescription fills for buprenorphine within 30 days after discharge among patients served by O-HQIP participating EDs. This represents a roughly 50% increase in net buprenorphine fill rates given a baseline rate of around 5%. Results also show that most of this increase was in the second year of program participation, suggesting that these programs may lead to gradual changes in practice patterns.

It is important to note that we used a difference-in-differences study design, meaning that our findings in participating hospitals were compared with non-participating hospitals to establish a causal relationship between participation and buprenorphine prescribing rates.

What should state and local decisionmakers take away from this?

State programs that encourage hospitals to increase their buprenorphine prescribing might be an important way to kickstart the adoption of gold-standard treatment for opioid use disorders in EDs. State policymakers might consider using their new opioid settlement funds to fund initial pilot programs in key hospitals and expand them throughout the state over time. Doing so could potentially save lives and reduce the burden of the opioid epidemic.