A Pilot of Emergency Department-Initiated Buprenorphine for Opioid Withdrawal and Opioid Use Disorder: A Quality Improvement Project

Background: Emergency department (ED) visits for opioid related visits have increased dramatically during the opioid epidemic. Buprenorphine is an evidence-based therapy for treating opioid use disorder (OUD) and withdrawal. Unfortunately, lack of access to pharmacotherapy for OUD, including buprenorphine, remains a challenge. Research supports ED-initiated buprenorphine as a practical, cost-effective strategy which engages patients in treatment better than non-pharmacologic alternatives. Purpose: The aims of this improvement project were to 1) develop a pilot process in an ED for providing buprenorphine to patients in opioid withdrawal or for OUD; 2) recruit and train a cohort of ED staff on the process; and 3) track the process as it was offered to patients. Methods/Interventions: Based on protocols from national and regional examples, a process for ED-initiation of buprenorphine was developed. Using a Diffusion of Innovation model, the project trained an influential cohort of staff. Buprenorphine waiver training was facilitated for ED physicians. In-person and virtual trainings on the process were conducted by the project leader. Written case reports for patient encounters were completed by providers/staff. Results: Guidelines were vetted and approved by hospital committees. 6 out of 10 full-time ED physicians (60%) obtained buprenorphine waivers. Pilot program trainings were provided to 34 staff directly and a recorded training was distributed. Within the first month of implementation, 16 unique case reports of encounters were collected. Case reports showed high rates of adherence to the following steps of the process: COWS scores performed (87.5%), buprenorphine administered for COWS score ≧8 (100%) discharged with prescription after ED dosing (77.8%), home induction prescriptions for COWS<8 (100%), cases discharged with prescription (87.5%), and referral to care coordination services (81.25%). Lower rates of adherence to process steps of involvement of recovery coaches (56.25%) and provision of overdose education/naloxone (33.3%) were noted. Process barriers included difficulties with entries in electronic medical record (EMR), a patient who did not get relief, and a patient who declined buprenorphine. Suggestions for improvement included easier order entry, clearer documentation of COWS score and challenges in locating forms. Conclusion: This project resulted in a new ED process affording access to buprenorphine where it was previously unavailable. A majority of ED physicians (60%) became waivered to prescribe buprenorphine. This percentage is well above a targeted 13.5% to reach a critical mass hypothesized to sustain a diffusion of this innovation. The odds of improved outcomes resulting from buprenorphine exposure including sustained recovery and reduced overall morbidity and mortality for patients exposed in this project are improved. Despite limitations in data accuracy, lessons learned about the process including barriers and opportunities for improvement may be valuable to other organizations as they develop their own systems. Further analysis of the project including future statistical process control measures and collection of more data using the electronic record will be valuable.