ED physicians not prepared to prescribe buprenorphine

While treating patients who have opioid use disorder (OUD) with buprenorphine is known to decrease opioid use and prevent morbidity and mortality, clinicians have low levels of readiness to actually prescribe the drug, according to a survey of attending, resident, and emergency physicians.

On the other hand, these same clinicians indicated a willingness to learn how to safely initiate the treatment, if they have sufficient support.

The results and analysis of the survey were published in JAMA Network Open.

According to the authors, led by Kathryn F. Hawk, MD, Department of Emergency Medicine, Yale School of Medicine, despite the availability of treatments for OUD, such as methadone or buprenorphine, as well as clinical guidelines supporting the use of these medications, “as many as 80% of patients do not receive such potentially life-saving treatments.”

The authors also noted that while emergency departments (EDs) have emerged as a key location to identify patient with OUD and to initiate treatment with buprenorphine, ED-initiated buprenorphine for these patients has been limited. Therefore, Hawk and colleagues evaluated the barriers to/ facilitators of readiness among clinicians to initiate buprenorphine in the ED in order to identify opportunities to promote readiness to initiate the treatment.

The authors performed a mixed-methods evaluation of 268 attending physicians ( n=113), resident physicians (n=107), and advanced practice clinicians (n=48) in four academic emergency departments in Baltimore, New York, Cincinnati, and Seattle.

Hawk and colleagues conducted a web-based survey that collected data on demographic characteristics, training, and experiences with ED-initiated buprenorphine, as well as focus groups discussions with physicians to identify barriers and facilitators to buprenorphine prescribing. They quantitatively assessed clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED, based on a visual analog scale in which clinicians were either categorized as less ready or most ready to initiate treatment in the ED.

Of those 268 physicians, only nine (3.5%) had completed Drug Addiction Treatment Act (DATA) of 2000 training, while 56 physicians overall (20.9%), including 24 of 113 attending physicians (21.2%), 26 of 107 residents (24.3%), and 6 of 48 advanced practice clinicians (12.5%), indicated a high readiness to initiate buprenorphine in the ED.

Hawk and colleagues determined that barriers to adoption of ED-initiated buprenorphine included:

  • A lack of formal training.
  • Limitations on time.
  • Limited knowledge of local treatment resources.
  • Absence of local protocols and referral networks.

On the other hand, facilitating physician readiness to initiate buprenorphine in the ED could be accomplished by providing more education and training, establishing clinical protocols for buprenorphine administration and prescribing, and enhancing communication across different stakeholder groups, they wrote.

“Together, these data are critical for guiding future implementation efforts to ensure that more patients with OUD receive potentially life-saving treatment with buprenorphine when seen in the ED,” wrote Hawk and colleagues, adding that these factors should be considered when implementing strategies for attending physicians, residents, and APCs to initiate buprenorphine in the ED.

Hawk and colleagues also noted that residents and APCs — and, to a lesser extent, attending physicians — were enthusiastic about learning how to initiate buprenorphine in the ED, with the caveat that they required clear support from departmental leadership, and the development of local protocols and clinical guidelines to facilitate their ability to implement practice change.

In a commentary accompanying the study, Howard S. Kim, MD, MS, Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, and Elizabeth A. Samuels, MD, MPH, MHS, Department of Emergency Medicine, Alpert Medical School of Brown University, wrote that in order to effectively train clinicians to prescribe buprenorphine, several strategies should be followed.

For example, gaps in medical knowledge, such as that pertaining to buprenorphine pharmacology and clinical indications, need to be closed. This can be done, wrote Kim and Samuels, through in-services education, as well with formal curricula for clinicians in training.

“Importantly, most undergraduate and graduate medical education program curricula do not substantively address [medications for OUD], thus forcing clinicians to obtain extracurricular buprenorphine-specific education, which is a known significant barrier to buprenorphine prescribing,” they wrote. “Integrating buprenorphine education into medical training nationally would not only better prepare clinicians to successfully care for patients with OUD but also obviate the need for DATA 2000–specific training.”

  1. Most emergency department physicians are not prepared to initiate the use of buprenorphine for patients with opioid use disorder.

  2. However, many of these physicians, with the proper support, are willing take the steps necessary to safely initiate the treatment.

Michael Bassett, Contributing Writer, BreakingMED™

Hawk reported receiving grants from the National Institute on Drug Abuse (NIDA)/National Institutes of Health (NIH) during the conduct of this study.

Cat ID: 254

Topic ID: 253,254,254,730,192,144,151,925