“Just give them a choice”: Patients' perspectives on starting medications for opioid use disorder in the ED

Abstract

Objectives: Medications for opioid use disorder (MOUD) prescribed in the emergency department (ED) have the potential to save lives and help people start and maintain recovery. We sought to explore patient perspectives regarding the initiation of buprenorphine and methadone in the ED with the goal of improving interactions and fostering shared decision making (SDM) around these important treatment options. Methods:We conducted semistructured interviews with a purposeful sample of people with opioid use disorder (OUD) regarding ED visits and their experiences with MOUD. The interview guide was based on the Ottawa Decision Support Framework, a framework for examining decisional needs and tailoring decisional support, and the research team's experience with MOUD and SDM. Interviews were recorded, transcribed, and analyzed in an iterative process using both the Ottawa Framework and a social-ecological framework. Themes were identified and organized and implications for clinical care were noted and discussed.Results: Twenty-six participants were interviewed, seven in person in the ED and 19 via video conferencing software. The majority had tried both buprenorphine

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

“…Even though treatment with buprenorphine has lifesaving properties on its own, people who are actively using or injecting drugs may not desire pharmacotherapy because of concerns about precipitated withdrawal, practitioner stigma, 10 lack of health insurance, 83 and high copayments. 84 , 85 Onsite harm reduction tools are not currently part of the traditional medical model 86 ; however, integrating harm reduction kits into care could provide patients with treatment autonomy and serve as tools for treatment engagement in times of active and/or chaotic use. 87 Our model for onsite harm reduction kits provided a fixed quantity of safer injection and wound care equipment that may not last 1 week (or even 1 day) for higher-frequency users.…”

Enhancing Patient Choice: Using Self-administered Intranasal Naloxone for Novel Rapid Buprenorphine Initiation

“…The described approach has potential for home or outpatient settings. It allows flexible timing as to a person's last use of fentanyl, provides more autonomy in starting BUP-NX, makes use of intranasal naloxone availability, and better aligns with the short time when beginning treatment is especially salient—paralleling “Quick Start” methods for contraception initiation 4,16 . In addition, the expedited timeline may appeal to patients with work, family, or other obligations.…”

“…It allows flexible timing as to a person's last use of fentanyl, provides more autonomy in starting BUP-NX, makes use of intranasal naloxone availability, and better aligns with the short time when beginning treatment is especially salientparalleling "Quick Start" methods for contraception initiation. 4,16 In addition, the expedited timeline may appeal to patients with work, family, or other obligations. Depending on their preferences, patients could make this transition on their own, with a peer recovery specialist or other trusted person, or with a clinician.…”

“…Unfortunately, this precipitation risk increases with regular fentanyl use—likely because of fentanyl's lipophilicity, which leads to a large volume of distribution and slow dissipation when used chronically 3 . Patients have significant concerns about the severity of withdrawal needed to start buprenorphine as well as the risk of precipitated withdrawal; the possibility of a negative experience understandably fosters hesitance to begin treatment 4–6 …”

“…3 Patients have significant concerns about the severity of withdrawal needed to start buprenorphine as well as the risk of precipitated withdrawal; the possibility of a negative experience understandably fosters hesitance to begin treatment. [4][5][6] Newer methods for BUP-NX initiation have been reportedgenerally categorized as very low-(or "microdosing"), low-, standard-, and high-dose (or "macrodose") protocols-each with potential benefits and risks (Table 1). 7,10 Less common methods use transdermal, buccal sublingual, and intravenous buprenorphine formulations not readily available for this outpatient purpose.…”