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Emergency department interventions for opioid use disorder: A synthesis of emerging models

      Highlights

      • ED-based OUD efforts are motivated by ED champions, rewarding work, and funding.
      • Barriers include lack of information, stigma, outpatient capacity.
      • Facilitators: a person-centered low-barrier approach and tracking performance.
      • Established ED programs are expanding to treat other substance use disorders.
      • Efforts are needed to make patient-centered OUD treatment standard in all EDs.

      Abstract

      Introduction

      Opioid overdose deaths are increasing, and improving access to evidence-based treatment is necessary. Emergency department (ED) initiation of treatment for opioid use disorder (OUD) via medications and referral to treatment is one approach that leverages a critical health care entry point for individuals with OUD. Efforts to engage patients in treatment through the ED are growing, but systematic analysis of program features as implemented and challenges across different models remains limited. Lessons from early adopter programs may benefit clinicians and others looking to offer ED-initiated treatment for OUD.

      Methods

      We conducted case studies of five ED-based efforts to address OUD across the United States, selected for diversity in structure, approach, and geography. We conducted telephone interviews with 37 individuals (ED physicians, ED nurses, navigators, hospital administrators, community providers, and state policymakers) affiliated with the five programs. Interviews were transcribed, coded, and analyzed using a framework analysis approach, identifying relevant lessons for replication.

      Results

      These five programs (an academic medical center, two large urban hospitals, a rural community hospital, and a community-based program) successfully implemented ED-initiated MOUD. Often a champion with knowledge of OUD treatment and a reliable connection with outpatient treatment began the program. The approach to patient identification varied from universal screening to relying on patient self-identification. Substance use treatment navigators provide crucial services but can be difficult to pay for within current reimbursement frameworks. Barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies. Facilitators of success include taking a patient-centered, low-barrier approach, having a passionate champion, a strong structure with health system support, and a relationship with community partners. Metrics for success vary across programs. Some programs are expanding to include treating the use of other substances such as alcohol and stimulants.

      Conclusion

      ED-initiated MOUD is feasible across different settings. Research and real world efforts need to promote programs that include OUD treatment as standard in ED treatment.

      Keywords

      1. Introduction

      The United States is facing a crisis of opioid overdose deaths. Drug overdose deaths exceeded 100,00 in the 12 months through October 2021, with more than 70 % including an opioid (
      • Centers for Disease Control and Prevention
      Drug Overdose Deaths.
      ). Although effective treatments exist (
      • Bart G.
      Maintenance medication for opiate addiction: The foundation of recovery.
      ;
      • Schackman B.R.
      • Leff J.A.
      • Polsky D.
      • Moore B.A.
      • Fiellin D.A.
      Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.
      ;
      • Thomas C.P.
      • Fullerton C.A.
      • Kim M.
      • Montejano L.
      • Lyman D.R.
      • Dougherty R.H.
      • Delphin-Rittmon M.E.
      Medication-assisted treatment with buprenorphine: Assessing the evidence.
      ;
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—Tackling the opioid-overdose epidemic.
      ), most people with opioid use disorder (OUD) go untreated, resulting in severe clinical and public health consequences (
      • Centers for Disease Control and Prevention
      2018 annual surveillance report of drug-related risks and outcomes- United States.
      ;
      • Honein M.A.
      • Boyle C.
      • Redfield R.R.
      Public health surveillance of prenatal opioid exposure in mothers and infants.
      ;
      • Mojtabai R.
      • Mauro C.
      • Wall M.M.
      • Barry C.L.
      • Olfson M.
      Medication treatment for opioid use disorders in substance use treatment facilities.
      ;
      • Wu L.-T.
      • Zhu H.
      • Swartz M.S.
      Treatment utilization among persons with opioid use disorder in the United States.
      ).
      For many individuals with OUD, contact with the health system occurs in the emergency department (ED) while experiencing an overdose or withdrawal symptoms. Mortality after ED visits for opioid overdose is high (
      • Houry D.E.
      • Haegerich T.M.
      • Vivolo-Kantor A.
      Opportunities for prevention and intervention of opioid overdose in the emergency department.
      ). A study of patients in Massachusetts EDs found that 5 % who survived an opioid overdose died within one year of ED discharge; 20 % of deaths were within one month of the ED visit, and 5 % of those (1.1 % of all deaths) were within two days (
      • Weiner S.G.
      • Baker O.
      • Bernson D.
      • Schuur J.D.
      One-year mortality of patients after emergency department treatment for nonfatal opioid overdose.
      ). Effective OUD treatment needs to be available and accessible with as few barriers as possible to save lives (
      • Howard B.
      Treating opioid addiction in the emergency department.
      ). Thus, EDs are one important place to serve as a critical entry point for individuals with OUD to access treatment (
      • Substance Abuse and Mental Health Services Administration (SAMHSA)
      Use of medication-assisted treatment in emergency departments (No. PEP21-PL-guide-5; p. 40).
      ).
      Clinical practice guidelines and treatment recommendations encourage medications for OUD (MOUD) as a first-line treatment, including in emergency departments (
      • American Society of Addiction Medicine
      The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update.
      ;
      • Centers for Disease Control and Prevention
      Opioid overdoses treated in emergency departments identify opportunities for action.
      ;
      • National Institute on Drug Abuse
      Principles of drug addiction treatment.
      , ;
      • Substance Abuse and Mental Health Services Administration
      Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction.
      ), but programs are implemented inconsistently across the country and researcher and treatment providers need more information regarding effective approaches (
      • American Society of Addiction Medicine
      The ASAM National Practice Guideline For the Treatment of Opioid Use Disorder 2020 Focused Update.
      ).
      ED-based efforts to address OUD take various approaches to provide low-barrier care. A low-barrier approach to treatment has the following qualities: 1) Same-day treatment entry, 2) Harm reduction, 3) Flexibility, and 4) Treatment availability in a variety of clinical settings (e.g., primary care, community-based settings, ED) (
      • Jakubowski A.
      • Fox A.
      Defining low-threshold buprenorphine treatment.
      ). In the ED, a low-barrier approach includes initiating MOUD and connecting patients with ongoing care, directly referring patients to community providers for OUD treatment, and offering harm reduction efforts such as overdose education and naloxone as a take-home emergency medication (
      • McGuire A.B.
      • Powell K.G.
      • Treitler P.C.
      • Wagner K.D.
      • Smith K.P.
      • Cooperman N.
      • Watson D.P.
      Emergency department-based peer support for opioid use disorder: Emergent functions and forms.
      ;
      • Stewart M.T.
      • Coulibaly N.
      • Schwartz D.
      • Dey J.
      • Thomas C.P.
      Emergency department–based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches?.
      ). ED efforts to support ongoing care take various structures, including navigators connecting patients with outpatient treatment, ED physicians connecting patients with co-located outpatient bridge clinics, or ED physicians with addiction medicine training continuing to see patients on an outpatient basis (
      • Martin A.
      • Butler K.
      • Chavez T.
      • Herring A.
      • Wakeman S.
      • Hayes B.
      • Raja A.
      Beyond buprenorphine: Models of follow-up care for opioid use disorder in the emergency department.
      ). Reports show ED-initiated MOUD is feasible and effective for helping patients engage in outpatient treatment; however, most are from individual hospital systems, with little systematic cross-site analysis of how programs implement features and what contributes to sustainability. (
      • Busch S.H.
      • Fiellin D.A.
      • Chawarski M.C.
      • Owens P.H.
      • Pantalon M.V.
      • Hawk K.
      • D’Onofrio G.
      Cost-effectiveness of emergency department-initiated treatment for opioid dependence.
      ;
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • Chawarski M.C.
      • Busch S.H.
      • Owens P.H.
      • Fiellin D.A.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial.
      ;
      • Dunkley C.A.
      • Carpenter J.E.
      • Murray B.P.
      • Sizemore E.
      • Wheatley M.
      • Morgan B.W.
      • Steck A.
      Retrospective review of a novel approach to buprenorphine induction in the emergency department.
      ;
      • Kaczorowski J.
      • Bilodeau J.
      • Orkin A.
      • Dong K.
      • Daoust R.
      • Kestler A.
      Emergency department-initiated interventions for patients with opioid use disorder: A systematic review.
      ;
      • Reuter Q.
      • Smith G.
      • McKinnon J.
      • Varley J.
      • Jouriles N.
      • Seaberg D.
      Successful Medication for Opioid Use Disorder (MOUD) program at a community hospital emergency department.
      ;
      • Snyder H.
      • Kalmin M.M.
      • Moulin A.
      • Campbell A.
      • Goodman-Meza D.
      • Padwa H.
      • Herring A.A.
      Rapid adoption of low-threshold buprenorphine treatment at California emergency departments participating in the CA bridge program.
      ),
      This article presents the results of five case studies of established and active ED programs that address OUD by synthesizing: how programs were motivated and initiated; variations in structure and staffing; program financing and sustainability; barriers to and facilitators of success; and lessons learned. Findings may help ED providers, administrators, and policymakers considering ED-initiated OUD treatment. To reduce the burden of OUD in the United States, effective and feasible approaches to treatment need to extend beyond early adopters to become part of standard care. In examining established programs, this study identifies key aspects of programs that EDs can implement broadly.

      2. Material and methods

      The study team identified case study sites based on a review of the literature (
      • Stewart M.T.
      • Coulibaly N.
      • Schwartz D.
      • Dey J.
      • Thomas C.P.
      Emergency department–based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches?.
      ) and interviews with subject matter experts, representing successful programs with varied models, structures (e.g., health system–based, state-based, individual ED), sizes, urban/rural area, and region. To recruit sites, an author (CPT) emailed the program director, summarizing the project and why their program may be an important model to include. The study offered each site an honorarium of $2000 for their time. One site declined participation, and researchers replaced it with another. Site leadership identified key persons for interviews in roles including ED physician, ED nurse, navigator, community partner, hospital administrator, and policymaker. When interviewees named additional individuals, the authors added them to the interview list. The university Institutional Review Board deemed the study exempt because it collects information about organizational policies and approaches to treating OUD rather than detailed information about the informants. The protocol adhered to the Standards for Reporting Qualitative Research (SRQR) guidelines; the SRQR checklist is available from the authors. All sites reviewed, validated, and approved program descriptions. Table 1, Table 2 describe participating sites and their characteristics.
      Table 1Program descriptions.
      ProgramLocationDescription
      Denver Health and Hospital Authority (DHHA)Denver, COHub and spoke model within an integrated health system; includes a range of disciplines and structural linkages for treatment.
      Marshall Medical CenterPlacerville, CARural community hospital not part of a larger health system; program noted by experts as successful. Small, part of the California Bridge program network.
      Highland Hospital, Alameda Health SystemOakland, CAOne of the largest programs; most experts referred to this program as an example of successful implementation, grown to a large network across California hospitals.
      New York MATTERSNew YorkStatewide program; began as regional and now operates in 17+ EDs and growing; maintains a database of 250 weekly appointments across NY state.
      Anchor EDRhode IslandStatewide program; Community program provider based; provides recovery personnel for EDs across the state; had state agency partnership at the beginning.
      Table 2Case study site descriptions: Approaches to key components of ED OUD programs.
      SiteApproach
      Case study siteStructurePatient identificationTreatment approachesRelationship with community programsFinancing
      All programs bill insurance where possible. This column refers to financing in addition to health insurance.
      Denver Health and Hospital Authority (DHHA)Hub & Spoke; integrated team across ED & BH departments, other spokesPatient self-identification, screening, community-based info. CampaignInitiate medication in ED and receive next day appointmentMost patients are linked to care within the DHHA systemInitially federal grants, now hospital funding
      Marshall Medical CenterRun by ED physician assistants, nurse practitioners, navigatorsPatient self-identification, screening, signs posted in ED, community outreachInitiate in ED and schedule follow-up appointment with partnersPartners with hospital's outpatient SUD clinic and four community health centersState and federal grants
      Highland Hospital, Alameda Health SystemRun by ED physicians, with navigators; close relationship with bridge clinicPatient self-identification; signs, pins, information posted in ED, community outreachInitiate in ED & warm handoff to bridge clinicBridge clinic next door is an ‘extension’ of the EDInitially grant-funded; now hospital funding
      New York MATTERSStatewide referral network & electronic platform; connects patients in ED & other settings with community-based treatmentVaries by partner siteInitiate in ED or provide Rx for home induction & schedule outpatient appointmentPartners with community-based outpatient treatment across the state; requires partners to sign Mission, Vision, Values statementState and federal grant funding
      Anchor EDOperated by a community-based organization; connects ED patients with peer recovery servicesVaries by hospitalPeers connect patients with community-based treatment and recovery resourcesPartnerships with several other community organizationsStarted with state funds
      Abbreviations, BH: Behavioral Health, Rx: Prescription.
      a All programs bill insurance where possible. This column refers to financing in addition to health insurance.
      Researchers conducted semi-structured interviews with 37 people over video conferences between February and May 2021. Interviews for all sites took place across the same period. At least two researchers (CPT, CAT, MTS, KS) conducted each interview, which averaged 45 min. Interview topics included development and motivation for starting the program, key program components, linkages with other organizations and how they have been nurtured, available evaluation data, funding, sustainability plans, and barriers and facilitators experienced. The study requested secondary data, including public reports and internal documents, from all sites to provide additional context.
      This study used framework analysis, a grounded, systematic approach to analyzing qualitative data (
      • Gale N.K.
      • Heath G.
      • Cameron E.
      • Rashid S.
      • Redwood S.
      Using the framework method for the analysis of qualitative data in multi-disciplinary health research.
      ;
      • Ritchie J.
      • Spencer L.
      Qualitative data analysis for applied policy research.
      ). Researchers became familiar with the topic by conducting a literature review; we then developed a set of codes to identify themes and concepts in the data. Researchers used deductive coding to create a list of preliminary codes from the interview guide topic areas. Interviews were recorded, transcribed, and double coded for multiple themes. The research team developed inductive codes as new themes emerged from the interview transcripts. Coders met regularly to discuss the codes and themes and ensure consensus on meaning. Coding discrepancies were infrequent, and researchers resolved them through discussion. Following coding, researchers organized the data in tables according to themes and then analyzed the data within and across programs to identify associations and provide explanations for the research questions.

      3. Results

      3.1 Factors motivating the development of ED-based interventions for OUD

      In interviews about how ED-based OUD efforts began, three themes came up: ED champions, rewarding work, and availability of new funding. All cases had a champion, often starting with one or two providers who obtained their Drug Abuse Treatment Act (DATA) 2000 waivers to prescribe buprenorphine. The champion helped to establish induction protocols and develop connections to outpatient treatment for a small number of patients. Motivators for implementation included a 2015 randomized trial demonstrating the effectiveness of initiating treatment in the ED and the Vermont hub-and-spoke model (
      • Brooklyn J.R.
      • Sigmon S.C.
      Vermont hub-and-spoke model of care for opioid use disorder: Development, implementation, and impact.
      ;
      • D’Onofrio G.
      • O’Connor P.G.
      • Pantalon M.V.
      • Chawarski M.C.
      • Busch S.H.
      • Owens P.H.
      • Fiellin D.A.
      Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial.
      ). The hub-and-spoke model is a system of care in which a hub (ED, specialty SUD treatment program, etc.) acts as a centralized referral source, connecting patients to a network of providers who provide care to individuals with chronic conditions (i.e., OUD). In some cases, the champion(s) had a partner champion from hospital administration or state or city government.
      Providers found treating OUD very rewarding. When treating people with OUD, providers felt they could help patients to access recovery and improve patients' lives. One explained, “Giving a patient with OUD, who feels very powerless, the ability to pick which clinic they want to go to and guarantee that the clinic will take them…is unbelievably empowering.”
      Most programs started with initial seed funding from grants, but additional funding was essential for these small initial efforts to grow. Substance Abuse and Mental Health Services Administration (SAMHSA) grant programs, including the Medication Assisted Treatment-Prescription Drug and Opioid Addiction (MAT-PDOA) and State Targeted Response to the Opioid Crisis, and State Opioid Response (STR/SOR) grants often played an important role, enabling the official pilot stage and protocol development for programs. With additional funding from city, county, state, hospital, or private grant sources, two programs were able to scale to offer nearly 24/7 access to buprenorphine treatment and same or next-day appointments.

      3.2 How study sites address key components of the ED OUD programs

      ED-based MOUD initiation efforts generally include several key components. Each site adapted key components to the needs and resources of its health system and community. Table 2 summarizes how case study sites address patient identification, treatment approach, program structure, relationships with community partners, and financing.

      3.2.1 Patient identification

      All programs accept patients who self-identify requesting treatment; two programs screen patients in the ED, and two programs encourage self-identification by advertising the program through signs throughout the ED and staff pins and badges. Highland Hospital relies entirely on patient self-identification using signs that say, “If you are struggling with pills or heroin, we can start you on buprenorphine today.” Similarly, most patients who start medication treatment through the Denver Health and Hospitals (DHHS) ED come to the ED in withdrawal from opioids and seeking treatment. One interviewee at the Denver program reported the program is “patient-driven; patients are not really approached by doctors.” The Marshall program takes a mixed approach: at least 50 % of patients who start MOUD in the ED self-identify, but the hospital screens patients for OUD and providers will ask if patients are interested in treatment. Other programs rely entirely on provider discretion. For example, the Anchor ED program, available to 11 hospitals in Rhode Island, does not routinely advertise to patients but conducts outreach to ED staff, reminding them of available Anchor ED services.

      3.2.2 Treatment approach

      Programs may initiate buprenorphine treatment in the ED, send patients home with a prescription for buprenorphine for home induction, or offer a warm handoff to a bridge clinic for initiating treatment. Bridge clinics are usually located close to the ED and may be part of the hospital system. Although bridge clinics are usually intended for short-term treatment, interviewees reported that patients could receive ongoing care if desired. Three ED-based programs (Denver, Marshall, Highland) focus on buprenorphine initiation in the ED. The statewide programs (NY MATTERS and Anchor ED) operate differently. NY MATTERS partners with EDs that initiate patients on buprenorphine and provides the MATTERS technology and network, which allows those EDs to connect patients with ongoing community-based treatment. The Anchor ED program provides peer supports to patients in the ED. If patients are interested in treatment, Anchor ED will link patients to outpatient treatment that includes medication or treatment that does not, acknowledging that “there are many paths to recovery.”
      Informants mentioned the desire to meet patients “where they are”. They reported that when other staff in the ED saw first-hand the improvement in patients' lives, the reduced number of ED visits, and the concrete help they could offer, the will to expand these programs increased dramatically. At the same time, stigma among providers regarding treating OUD patients decreased.

      3.2.3 Program structure

      The study cases operate within a range of systems, from rural community hospital that is not part of a larger system to a hub-and-spoke model in an integrated health system. The type of system in which the program operates influences how the ED connects patients with ongoing treatment. The Denver program, operating within an integrated health system, connects patients with an outpatient clinic in the DHHA system. Marshall Medical Center is a rural community hospital. The hospital connects patients with either the hospital's outpatient program or one of several community-based organizations geographically distributed across a large area. Highland Hospital connects patients to a bridge clinic that is not part of the hospital system but is located near the hospital and shares staff with the Highland ED. The key in each system is strong communication within the team and with the outpatient treatment sites.
      Four case studies are programs led by hospital-based staff (ED providers, physicians, or physician assistants), and a community-based recovery support services organization runs Anchor ED. ED providers reported that sometimes community-based organizations approach OUD differently, such as focusing on other pathways other than medication as a foundation of treatment.
      Substance use navigators are a key aspect of all ED OUD programs. Navigators are support staff who aim to link patients with substance use treatment and recovery services. All ED-based programs use navigators to help patients through the ED visit, assessment paperwork, and making connections with continuing health care. Some programs provide additional services beyond helping patients to connect with ongoing care; for example, assisting patients with accessing housing services or transportation. Programs vary in the type of staff acting as navigators. Four of the programs studied use navigators without clinical training to assist patients as they move through care; one program uses hospital social workers and behavioral health clinicians rather than navigators for this function. Programs vary in whether the navigators are peers with lived experience or individuals from the community who are not in recovery themselves. Table 3 shows the role of navigators for each case study site.
      Table 3Role of peers and navigators by case study site.
      Denver Health and Hospital Authority (DHHA)
      • Based in the behavioral health outpatient clinic; generally peers with lived experience
      • Help patients complete enrollment paperwork
      • Facilitate scheduling clinic appointments and arranging other services (e.g., transportation, housing, detoxification services)
      Marshall Medical Center
      • Based in the ED; peer navigators are knowledgeable about treatment system and aim to be experts in navigating the system
      • Acts as a link between patients, ED, clinic, and physicians
      • Respond to consult orders from throughout the hospital, discuss treatment options with patients
      • Link patients to the local clinic or clinics in their geographic area
      • Facilitate warm handoffs to care
      • Follow-up with patients who receive a referral
      Highland Hospital, Alameda Health System
      • Employed by the hospital and embedded in ED; generally not peers
      • Recruited from a mentoring program for underrepresented students groups (high school and college who are from the community
      • Meet with patients in the ED to take a history and assess needs/ desires for treatment; report back to ED physician
      • Helps to assure that the patient's needs are met (food, medication, etc.)
      • Provides connection to social services and resources, including bridge clinic
      • Responsible for follow-up with the patient after discharge from the ED
      New York MATTERS
      • The patient chooses whether they want to connect with a peer navigator
      • If yes, NY MATTERS notifies the peer-services organization affiliated with the hospital. If the hospital doesn't have a peer-services organization, they notify the state's affiliate
      • Structure and responsibilities vary by hospital/organization
      Anchor ED
      • Employed by the social service agency that runs the Anchor ED program and are peers in recovery
      • ED reaches out to Anchor to request a peer in the ED
      • Responsible for meeting patients in the ED within 30-min of ED's call
      • Try to build understanding and share lived experiences with patient
      • Discuss patient's treatment options; link patients to the option they choose
      • Link patient with a navigator for follow-up if desired
      Navigators may work embedded in the ED, or they may be on call within minutes. Several interviewees reported that having navigators embedded in the ED was more efficient and seamless. While acknowledged by all as critical to the success of ED OUD programs, respondents reported that peer navigators can face barriers to working in the ED and may not always fit with the ED culture. For example, interviewees noted that some peer navigators may have difficulty passing background checks required to work in the hospital. Finally, respondents reported that in some cases, peers may not advocate for MOUD and instead promote abstinence-based recovery, creating challenges for clinicians who are poised to initiate MOUD.

      3.2.4 Relationship with community-based treatment programs for follow-up

      In three programs, the ED connects patients with an outpatient program that is part of the hospital system (Denver, Marshall) or closely affiliated with the hospital (Highland). NY MATTERS focuses on developing relationships with community-based organizations and connecting patients from EDs across the state with these community-based providers. Anchor ED is a community-based recovery support services organization. Table 4 displays each program's referral options for ongoing treatment. Clinical experts reported that having a reliable outpatient program is critical to making physicians willing to offer buprenorphine induction in the ED. When clinicians know they have a reliable referral network and additional follow-up from the ED physicians or staff will not be required, they are more willing to start a patient on medication treatment.
      Table 4Approaches to connect patients with ongoing treatment.
      Denver Health and Hospital Authority (DHHA)Connects patients with the outpatient treatment and medical services as needed available through the hospital's outpatient behavioral health department.
      Marshall Medical CenterMaintains connections with several community health centers that provide outpatient treatment and the Marshall CARES clinic, an outpatient clinic right around the corner from the hospital, which helps mitigate transportation challenges. The CARES clinic is affiliated with the hospital and run by the hospital's behavioral health department.
      Highland Hospital, Alameda Health SystemConnects patients who start medication treatment in the ED with a low-barrier bridge clinic on the grounds of the hospital. The bridge clinic is not part of the health system. Bridge clinic receives state grant funding and works closely with the ED, including employing some of the ED staff.
      New York MATTERSDevelops and maintains relationships with community-based outpatient treatment providers and maintains a database of more than 250 available appointments weekly. Using a web-based interface, patients select a convenient outpatient program from the database and receive a referral for ongoing treatment.
      Anchor EDCommunity-based program. Connects patients in the ED with peer recovery specialists and stays in touch with patients following the ED visit. If patients are interested in MOUD and/or outpatient treatment, the peers and the Anchor program will help connect patients appropriately.
      Approaches to establishing partnerships varied by organization structure and location. Marshall had partnerships both within the hospital and with outside organizations. The hospital's organizational structure facilitated the internal partnership with the hospital's behavioral health department. Marshall staff reported that being in a rural community where everyone knows each other helps to facilitate communication and relationships among different organizations. Denver partnered with internal organizations as part of an integrated health system, and the organizational structure facilitated this relationship. For Highland hospital, the partnership with a low-barrier bridge clinic not affiliated with the hospital was facilitated by having shared staff members. Some ED staff, including an ED physician and care navigators, also work in the low-barrier bridge clinic, thus facilitating communication. The NY MATTERS program requires outpatient treatment program partners to agree to a shared mission, vision, and values statement to ensure all programs are patient-centered and operate with similar values (MATTERS ). The statement includes requirements that outpatient programs offer timely appointments to referred patients, not automatically disqualify patients from receiving OUD medication treatment if they engage in polysubstance use, and provide feedback to the ED provider regarding the disposition and treatment retention for referred patients.
      Interviewees describe additional collaborations to facilitate program reach and patient access to services. For example, Walgreens and Wegmans accept vouchers from NY MATTERS that cover patients' copayments for buprenorphine prescriptions. NY MATTERS is also working on a partnership with Uber to help patients with transportation. ED leadership from Highland Hospital actively reaches out to community-based providers, “We have partnerships with the county jail, the detox center, with other clinics that are treating patients with substance use disorders, the pain clinic, and the harm reduction coalition, and various community partners”. The mayor of Denver ran a public education campaign that drove demand to the DHHA program. Anchor ED is involved in state policy development and education of health care organizations in the state.

      3.2.5 Program financing

      Financing some aspects of ED-based OUD treatment programs is a concern for programs. According to interviewees, billing for work by non-clinical providers, such as navigators, is not always allowed by insurance companies. Therefore, organizations often pay for navigators using grant funds. One ED physician reported, “The least expensive staff are the hardest to pay for”. Another interviewee argued that paying a bundled rate for OUD treatment would provide financial flexibility to cover the costs of treating patients, providing MOUD, and employing navigators. The community-based program, Anchor ED, has relied on block-grant funding from the state and reports that sustainability is a concern.
      Interviewees are also concerned about low reimbursement rates for behavioral health services overall and reported that reimbursement rates do not always cover costs. One interviewee expressed frustration that reimbursement rates are higher for primary diagnosis of depression than for substance use disorder and argued, “If we don't have parity of reimbursement, we aren't going to have treatment”.

      3.3 Plans for continued implementation and sustainability

      Respondents described activities and structures that support program sustainability. These include measuring performance and sharing this information with hospital administration, hospital system support for the program, expanding programs to treat other substance use, and improving systems to bill insurance for navigator activities. Programs studied have become an integral part of the ED. An interviewee explained that once these programs are implemented, and administrators see the impact in performance reports, it is hard for leadership to eliminate them. Performance measures tracked by outpatient programs and shared with the ED include follow-up with the outpatient program, outpatient MOUD receipt, duration of medication treatment, and whether the patient uses MOUD for at least 90 days with the outpatient program.
      Hospital-system support facilitates sustainability. One hospital reported that having the hospital system buy-in to the navigator approach has helped with financing and sustainability. Another interviewee reported that although it is difficult to finance some aspects of the program, “It will be extremely difficult to extract [the program] from our department. We can continue services even if there isn't specifically designated grant funding for it”. One interviewee commented that if hospitals could employ peers directly, it would help with sustainability. For programs that remain grant-funded, however, the burden associated with seeking funding is a risk to program sustainability.
      Several hospitals are working on expanding their programs, in part as a way to improve sustainability. Most programs had plans to expand to treat substances beyond opioids to meet patients' changing needs and to use resources like navigators more efficiently. When navigators can bill for working with a larger number of patients beyond those with OUD, the cost of employing the navigator is easier for the hospital or program to recoup.

      3.4 Expanding programs to treat other substances, including stimulants and alcohol

      Interviewees noted that due to the success of the ED OUD programs, they have expanded or plan to expand their focus to address other substance use disorders (SUDs). Identification and treatment of alcohol use and stimulant use disorders were targets for programs to expand beyond OUD. Programs emphasized a low-barrier approach to OUD treatment including providing treatment to those using multiple substances. Interviewees explained that treating other SUDs can be more challenging because FDA-approved medications are not available for all substances. Expansion efforts were facilitated by the OUD programs' success in reducing stigma, increasing knowledge about SUDs and the populations affected by SUDs, and creating a culture of self-efficacy among providers.

      3.5 Barriers and facilitators to ED-based OUD efforts

      3.5.1 Barriers

      Table 5 lists barriers and facilitators to offering OUD treatment in EDs. Commonly identified barriers were stigma and lack of knowledge about treatment options and effectiveness, limited community treatment capacity, and health insurance and reimbursement policies. Several sites reported that physicians, nurses, and other staff were initially skeptical of medication treatment for OUD in part because of a lack of training. A hospital administrator reported that staff asked, “Is this a problem that needs this kind of intervention”? Another interviewee said that providers were afraid of doing harm, for example, by causing precipitated withdrawal, and this led to hesitancy to offer buprenorphine. Respondents explained that stigma among clinical staff regarding OUD makes it difficult to collaborate. One ED physician described stigma as an outgrowth of a lack of awareness of effective treatment: “A ‘those patients’ attitude is likely because they don't have a solution and don't want to feel bad at their job”.
      Table 5Barriers and facilitators of success.
      Barriers
      • Stigma associated with opioid use disorder and patients with OUD
      • Limited capacity and availability of reliable outpatient treatment and needed social supports
      • A lack of information and knowledge about OUD treatment
      • Concern about ED workflow
      • Coordination with outside organizations
      • Lack of insurance, cumbersome intake policies, and medication costs
      • Funding sources for uncovered services
      • Buprenorphine x-waiver requirements
      Facilitators
      • Patient-centered, low barrier approach to promote uptake of treatment
      • A passionate champion and expert in OUD treatment
      • Strong structure to facilitate communication across partners and seamless treatment
      • Tracking of performance allows monitoring, adjustments, and rationale for sustaining the program
      • Flexibility during the COVID-19 Pandemic
      Difficulties connecting patients with outpatient care resulted in sending patients to less appropriate levels of care, “There are capacity issues in terms of seeing everyone in the ED and then finding a next-day place to send the patients. The result is that the team is not always linking patients to the right level of care”. Another site reported a lack of capacity for higher levels of care. Similarly, another interviewee described challenges with finding outpatient treatment for patients, “ED folks are overwhelmed. They are constantly asked to do research for this or linkages to that. They are saying, ‘I am just trying to keep this person alive.’ That is where the champion comes in to help push and streamline the process”. Many interviewees maintained that more comprehensive services and stable links with outpatient care are needed, including securing housing and other supports for some patients.
      Lack of insurance, insurance policies, high cost of medication copayments, and reimbursement policies are barriers. One interviewee reported that lack of insurance, “stops a lot of people from seeking care. Paying out of pocket is not always possible for patients”. Prior authorization requirements for buprenorphine are a barrier requiring ED staff time to address. Another interviewee described the counseling intake process requiring medical necessity and psychosocial screening as onerous and difficult for someone to complete while using substances or in withdrawal. Some sites that use navigators expressed difficulty paying for these staff when they cannot bill insurance for navigators' activities. One interviewee explained, “The hardest thing is to pay for the peer-recovery coaches/navigators even though they are the lowest-paid people in the hospital because it is not clear how to bill for them. However, they are a key to all of this as they are extremely helpful with reducing stigma for patients”. Interviewees reported that financing mechanisms with more flexibility (e.g., bundled payments) to cover the cost of navigators were uncommon but needed.

      3.5.2 Facilitators

      Facilitators of success include taking a person-centered, low-barrier approach, having a passionate champion, strong structure, and tracking performance. Lowering barriers to care in the ED—mentioned by all programs as critical—is accomplished through approaches such as having navigators available promptly to interact with patients; facilitating follow-up with next-day appointments, transportation, and warm handoffs; treating people with SUD with respect; letting patients make their own decisions; and establishing a mission statement as noted earlier for NY MATTERS.
      The interviewees at all sites addressed the importance of “Going to the bedside and talking to patients and treating patients as humans”. Several sites described the importance of “Engaging patients at whatever level they want to engage in” and “Meeting people where they are and getting them into treatment at whatever level the patient wants: medication treatment only is fine, medication and counseling is fine, counseling only is also available”. Another interviewee said their program “Takes patients with few rules and restrictions/requirements, and then transfers them to [ongoing outpatient] care only if that is what they want; they can also choose primary care or be kept within the program”. A navigator described helping a patient using opioids and methamphetamine start buprenorphine. The patient was able to start treatment despite other drug use and asked for help with the methamphetamine use after a period of time. Interviewees universally endorsed the importance of treating patients with respect and putting them in control of their treatment.
      Across the five case studies, sites had passionate and motivated champions who implemented ED-based OUD treatment at their site. All are knowledgeable about OUD treatment and buprenorphine, have earned the trust and respect of their colleagues, and worked to educate others on the team about the importance of buprenorphine. Most champions started offering ED-based OUD treatment independently and grew the program as colleagues saw the possibilities and began to understand how much it could help patients. Programs expanded beyond the ED to other departments when those departments (e.g., OB/GYN, pediatrics) had their champions. Similar to other studies' findings (
      • Hawk K.F.
      • D’Onofrio G.
      • Chawarski M.C.
      • O’Connor P.G.
      • Cowan E.
      • Lyons M.S.
      • Edelman E.J.
      Barriers and facilitators to clinician readiness to provide emergency department–initiated buprenorphine.
      ;
      • Kim H.S.
      • Samuels E.A.
      Overcoming barriers to prescribing buprenorphine in the emergency department.
      ), organizational facilitators include support and readiness of the hospital or health system to provide resources and personnel for the program, secure funding, and allow providers' autonomy to develop programs. Program leadership and stakeholders reported that having direct contact with outpatient programs to communicate about treatment beds and outpatient appointments in a timely manner furthered patient care and facilitated ED provider cooperation and trust in the program's effectiveness.
      Interviewees reported monitoring ED performance and feeding that information back to clinicians with stories of success as helpful for motivating providers. Sharing feedback and success stories about people who successfully engage with outpatient treatment with the ED providers can generate excitement and motivation for this work. Without this feedback, ED providers only see the patients who do not do well. One interviewee explained that tracking and sharing data with hospital administrators and with the community facilitated goodwill for the program and made obtaining necessary funding from the hospital easier. Three sites described the importance of educating nurses and receiving their support to have a successful program. An interviewee explained, “Getting nurses to see the importance of the program was critical because nurses spend the most time with patients”. Through education and culture change, sites were able to achieve nursing support. Programs operating out of an integrated health system or with very close relationships with outpatient treatment programs were better able to assess performance and obtain hospital funding for the programs.

      4. Discussion

      A systematic approach to OUD treatment in the ED is feasible across a range of different ED structures, including an academic medical center, large urban hospital, and rural community hospital, and is often rewarding for providers. As found in recent studies (
      • Hawk K.F.
      • D’Onofrio G.
      • Chawarski M.C.
      • O’Connor P.G.
      • Cowan E.
      • Lyons M.S.
      • Edelman E.J.
      Barriers and facilitators to clinician readiness to provide emergency department–initiated buprenorphine.
      ;
      • Kim H.S.
      • Samuels E.A.
      Overcoming barriers to prescribing buprenorphine in the emergency department.
      ;
      • Lowenstein M.
      • Kilaru A.
      • Perrone J.
      • Hemmons J.
      • Abdel-Rahman D.
      • Meisel Z.F.
      • Delgado M.K.
      Barriers and facilitators for emergency department initiation of buprenorphine: A physician survey.
      ), among early-adopter programs, successful efforts require champions with knowledge of OUD treatment, a reliable link with outpatient treatment, and a hospital system that is ready to provide support. Successful innovation requires a confluence between system antecedents, characteristics of the technology, and communication between leaders and staff (
      • Greenhalgh T.
      • Robert G.
      • Macfarlane F.
      • Bate P.
      • Kyriakidou O.
      Diffusion of innovations in service organizations: Systematic review and recommendations.
      ;
      • Rogers E.M.
      Diffusion of innovations (5th ed).
      ), factors evident in the programs studied.
      We found the approach to patient identification varied, which may influence workload. Programs that screen for OUD and ask all patients with possible OUD about treatment will have a larger base of patients identified than those who include only patients requesting treatment. The approach to identification is also likely to influence evaluation results because programs will vary in the type of patient they identify and whether patients are likely to start treatment. Training for staff can be helpful, and when other providers and staff witness the effectiveness of ED-initiated MOUD, motivation for the program grows. Regarding sustainability, all programs identified plans to continue operation. Some are expanding to address other SUDs, in part because of the perceived effectiveness of the program with OUD and in part because the need is clear and helping more patients may improve program efficiency. Providing ED-based OUD treatment is helping to change the culture of these EDs and to embed OUD treatment as a core component of the ED. One program plans to implement a patient registry, develop a training academy for providers, and improve system-wide approaches to bill for navigators.
      This research suggests several steps to support the development and implementation of ED-based OUD treatment. As successful ED OUD program models emerge, much can be learned from current efforts to provide guidance to nascent programs and systems interested in developing ED-based OUD interventions. Therefore, opportunities exist to facilitate program development by offering additional venues for learning collaboratives, including sharing models, challenges, and successes. These venues can also provide a forum for developing and testing guidelines and standardized measures and tools to more effectively measure change and impact. Learning collaboratives can also serve as an important vehicle for dissemination. Educational efforts are warranted for providers and the community to improve awareness and knowledge about OUD treatment options and to address stigma. Our study found that stigma occurs among providers within and beyond the ED and within the community.
      Addressing the challenges of inadequate funding of ED OUD programs presents another opportunity. Programs studied were generally started with limited resources; however, to sustain and grow, financial support was critical, consistent with barriers documented elsewhere (
      • Hawk K.F.
      • D’Onofrio G.
      • Chawarski M.C.
      • O’Connor P.G.
      • Cowan E.
      • Lyons M.S.
      • Edelman E.J.
      Barriers and facilitators to clinician readiness to provide emergency department–initiated buprenorphine.
      ;
      • Stewart R.E.
      • Wolk C.B.
      • Neimark G.
      • Vyas R.
      • Young J.
      • Tjoa C.
      • Mandell D.S.
      It’s not just the money: The role of treatment ideology in publicly funded substance use disorder treatment.
      ). Programs suggested financing models that include adequate coverage for nonclinical personnel critical to the program, such as recovery navigators or peer navigators, is key to sustainability. Federal grant programs, including the Medication Assisted Treatment Prescription Drug and Opioid Addiction and STR/SOR grants, were instrumental in numerous cases to the early development of the programs studied. Once programs are established, they may become incorporated into hospital budgets. However, many must continue seeking grant funding. Payment models, such as bundled payments, that address gaps in insurance benefits are important to consider, as well as enhanced reimbursement for essential services that are not sufficiently reimbursed.
      Because programs use a range of metrics for their own purposes, the field needs a systematic approach to identifying and assessing ED-based MOUD efforts, including evaluating the impact of key features. Systematic information on patient perspectives on these programs would help to further elicit information about improving services. Finally, additional analyses of the cost-effectiveness and sustainability of programs are useful in supporting growth. Many programs report that they have anecdotal information about the effectiveness of programs, but without more rigorous data on effectiveness and cost, maintaining efforts, especially if grant funding is no longer available, will be difficult.
      More research should investigate barriers in EDs that have not yet started offering MOUD and how to support and encourage expansion of ED-based MOUD initiation. The cases included here were early and enthusiastic adopters of ED-based MOUD initiation; later-adopting programs may face different barriers and require different implementation strategies to support offering MOUD. Studies should look at whether a top-down or a bottom-up approach to expanding ED-based MOUD is best. Studies should also research how best to identify patients for OUD treatment and how best to successfully support patients as they engage in outpatient treatment. Research should report on how many lives are saved and the negative health outcomes and ED visits avoided because of the availability of OUD treatment in EDs. This information would help as EDs consider expanding access to medication for OUD. However, even without this research, key informants argue EDs have available effective treatments, and if they identify patients with OUD, they must also offer medication treatment.
      Our study has limitations. The team planned field research just prior to the COVID-19 pandemic and the accompanying burden on hospitals and travel restrictions. Therefore, the team conducted all of the interviews for this project virtually rather than in person. Established programs were purposefully selected for case studies. These programs are early adopters of ED-initiated OUD treatment. Our findings may not generalize to other hospitals or the many hospitals that are not yet providing ED-based OUD treatment (
      • Hawk K.F.
      • D’Onofrio G.
      • Chawarski M.C.
      • O’Connor P.G.
      • Cowan E.
      • Lyons M.S.
      • Edelman E.J.
      Barriers and facilitators to clinician readiness to provide emergency department–initiated buprenorphine.
      ;
      • Lowenstein M.
      • Kilaru A.
      • Perrone J.
      • Hemmons J.
      • Abdel-Rahman D.
      • Meisel Z.F.
      • Delgado M.K.
      Barriers and facilitators for emergency department initiation of buprenorphine: A physician survey.
      ). Different organizational structures may require different approaches to facilitate program implementation. We spoke with hospital staff and providers in a range of different roles who were supporting ED-initiated medication for OUD. Other staff, including ED physicians in these organizations, may not offer ED-initiated OUD medication. Additional barriers may exist in EDs that are not yet providing ED-based OUD treatment. Our study did not include interviews with patients, and their perspectives will ensure that services are patient-centered, accessible, and welcoming.

      5. Conclusion

      Improved access to OUD treatment will help to save lives. The ED is an important setting to offer and initiate OUD treatment. EDs can reduce barriers to OUD treatment, facilitating a start to treatment for patients, as they are often ready at the time they present to the ED. EDs can reduce barriers by offering services in the ED, expanding capacity for treatment in the community within days of being seen in the ED, ensuring availability of treatment on demand and 24-h follow-up, and engaging in ongoing efforts to make the culture of the ED and SUD treatment more broadly welcoming to all patients.

      Presentations

      Earlier versions of the paper were presented as virtual posters at the Academy Health Annual Research Meeting in June 2021 and the Addiction Health Services Research Annual Meeting in October 2021.

      Financial support

      This study was supported by ASPE Contract # HHSP233201600012I 75P00119F37001.

      CRediT authorship contribution statement

      CPT: Study concept and design, acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; revision of the manuscript for important intellectual content; acquisition of funding. MTS: Study concept and design, acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; revision of the manuscript for important intellectual content. CT: Acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; revision of the manuscript for important intellectual content. KS: Acquisition of the data; analysis and interpretation of the data. DS: Study concept and design, acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; revision of the manuscript for important intellectual content. JD: Study concept and design, acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; revision of the manuscript for important intellectual content.

      Declaration of competing interest

      The authors declare no financial conflicts of interest for this work.

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